Pilgrim 2016011 Final

J.
Dent
UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION I
2100 RENAISSANCE BLVD., SUITE 100
KING OF PRUSSIA, PA 19406-2713
May 10, 2017
EA-17-023
Mr. John Dent

Site Vice President
Entergy Nuclear Operations, Inc.
Pilgrim Nuclear Power Station
600 Rocky Hill Road
Plymouth, MA 02360-5508
SUBJECT: PILGRIM NUCLEAR POWER STATION SUPPLEMENTAL INSPECTION

REPORT (INSPECTION PROCEDURE 95003 PHASE C) 05000293/2016011
AND PRELIMINARY GREATER-THAN-GREEN FINDING
Dear Mr. Dent:
On January 13, 2017, the U.S. Nuclear Regulatory Commission (NRC) completed the on-site
portion of a supplemental inspection at Pilgrim Nuclear Power Station (PNPS) using Inspection
Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple
Degraded Cornerstones, Multiple Yellow Inputs, or One Red Input. On March 21, 2017, the
NRC inspection team discussed the results of this inspection with you and other members of
your staff at a public exit meeting. The results of this inspection are documented in the
enclosed report.
The NRC performed this inspection to review your stations actions in response to PNPSs
transition into the Repetitive Degraded Cornerstone Column (Column 4), as discussed in the
2015 mid-cycle assessment letter, dated September 1, 2015 (ML15243A2591). The NRC
completed the Phase A portion of this supplemental inspection on January 15, 2016
(ML16060A018). The Phase A inspection was performed to review aspects of PNPSs
corrective action program to determine whether continued operation of PNPS was acceptable
and whether additional regulatory actions were necessary to arrest declining plant performance.
The NRC completed the Phase B portion of this supplemental inspection on April 8, 2016
(ML16144A027). The Phase B inspection was performed to review Entergys overall corrective
action program performance since the last biennial problem identification and resolution
inspection in August 2015. On September 2, 2016, you informed the NRC that your station was
ready for Phase C of the supplemental inspection.
The NRC determined that programs and processes at PNPS adequately support nuclear safety
and that PNPS should remain in Column 4. Inspection Manual Chapter (IMC) 0305, Reactor
Oversight Assessment Process, Section 10.02e (ML16257A522), provides examples of
1
Designation in parentheses refers to an Agencywide Documents Access and Management System
(ADAMS) accession number. Documents referenced in this report are publicly available using the
accession number in ADAMS.
J. Dent 2
unacceptable performance which represent situations in which the NRC lacks reasonable
assurance that the licensee can or will conduct its activities to ensure protection of the public
health and safety. With respect to these examples, the NRC has not identified: 1) multiple
escalated violations of PNPSs license, technical specifications, regulations, or orders; 2)
multiple safety-significant examples where the facility was determined to be outside of its design
basis; or 3) a pattern of failure by Entergy management to effectively address previous
significant concerns to prevent recurrence. While gaps in performance were identified during
this inspection, the NRC determined that the above examples of unacceptable performance
were not met. In particular, the NRC noted that licensed operators demonstrated, both in the
control room and the simulator, the ability to effectively respond to events to place the reactor in
a safe condition, consistent with their licensed responsibilities. The NRC also observed some
improvement in corrective action program performance and a reduction in the number of
operational events that resulted in a reactor scram.
Because the NRC had not completed the supplemental inspection for the White finding related
to the A safety/relief valve (SRV) prior to this inspection, the scope of this inspection also
included a review of that issue using IP 95001, Supplemental Inspection Response to Action
Matrix Column 2 Inputs. As described in Section 4 of this inspection report, the NRC
determined that the collective issues associated with the methodologies in the associated root
cause evaluation (CR-PNP-2016-01621) represented a significant weakness, such that the
objectives of IP 95001 could not be satisfied. Most notably, incorrect conclusions and
assumptions related to the adequacy of information in the condition report originally written for
the A SRV operation in 2013 ultimately resulted in Entergy inappropriately assessing the
impact of lack of rigor in shift manager operability determination review of an operability
determination and any associated causal factors, in the root cause evaluation. Accordingly,
Entergy will need to take action to address the deficiencies identified above, and the NRC will
verify, through inspection follow-up activities, that the objectives of IP 95001 for this issue are
met.
Based on the results of this inspection, as well as consideration of recent events at the station,
the NRC identified deficiencies that warrant Entergys immediate attention. Primarily, revisions
are needed to your Comprehensive Recovery Plan for PNPS to ensure that performance
improvements will be achieved and sustained. Specifically:
Adjustments to corrective actions or compensatory measures to assure that the

corrective actions to preclude repetition documented in the Comprehensive Recovery
Plan will drive sustainable performance improvement;
Inclusion of corrective actions to address the significant weaknesses identified during

review of the root cause evaluation for the White SRV finding;
A description of how Entergy is planning to address gaps identified by Phase C of the

IP 95003 inspection associated with the rigor with which senior licensed operators
assure the plant is operated within its design bases (including operability determinations,
technical specification knowledge, and questioning attitude);
A review and analysis of the effectiveness of Entergys implementation of subject matter

experts and mentors, including any potential expanded scope needed to drive sustained
performance improvement; and
J. Dent 3
A description of how Entergy is addressing gaps in procedure use and adherence, which
have resulted in recent events2 at PNPS.
Additionally, Entergy needs to implement current Comprehensive Recovery Plan actions in a

more rigorous and thoughtful manner to achieve substantial and sustainable performance
improvement.
Once Entergy submits PNPSs revised Comprehensive Recovery Plan to the NRC, the NRC will
review your plan and issue a Confirmatory Action Letter to confirm Entergys key actions.
These actions, if effectively implemented and independently verified by the NRC through
inspection follow-up activities, will be considered by the NRC in determining whether PNPS
should transition out of Column 4 of the NRCs Action Matrix, in accordance with IMC 0305,
Operating Reactor Assessment Program.
The enclosed report documents a finding that the NRC has preliminarily determined to be of
greater than very low safety significance (i.e., greater than Green). As described in Section
6.7.4, the finding is associated with an apparent violation of Title 10 of the Code of Federal
Regulations (10 CFR) Part 50, Appendix B, Criterion III, Design Control, in that Entergy did not
account for potential new failure mechanisms on a new component, a relief valve, on the right
angle drive for the A emergency diesel generator radiator blower fan. As a result, Entergy did
not consider the need to periodically monitor or maintain the valve, which subsequently failed,
resulting in the inoperability of the A emergency diesel generator for a period greater than its
technical specification allowed outage time of 14 days. The finding was assessed based on the
best available information, using IMC 0609.04, Initial Characterization of Findings, and Exhibit
2 of IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-
Power, issued June 19, 2012. The basis for the NRCs preliminary significance determination
is described in the enclosed report.
The apparent violation of NRC requirements associated with this finding is being considered for
escalated enforcement action in accordance with the Enforcement Policy, which appears on the
NRCs Web site at http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html.
Because the NRC has not made a final determination in this matter, no notice of violation is
being issued for this inspection finding at this time. In addition, please be advised that the
number and characterization of the apparent violation may change based on further NRC
review. The NRC will inform you, in writing, when the final significance has been determined.
We intend to complete and issue our final safety significance determination within 90 days from
the date of this letter. The NRCs Significance Determination Process is designed to encourage
an open dialogue between your staff and the NRC; however, the dialogue should not affect the
timeliness of our final determination.
Before we make a final decision, we are providing you an opportunity to provide your
perspective on this matter, including the significance, causes, and corrective actions, as well as
any other information that you believe the NRC should take into consideration. Accordingly, you
may notify us of your decision within 10 days to: (1) request a regulatory conference to meet
with the NRC and provide your views in person; (2) submit your position on the finding in writing;
or (3) accept the finding as characterized in the enclosed inspection report.
2
Event notification reports 52643 (March 27, 2017) and 52655 (March 31, 2017), available at
https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2017
J. Dent 4
If you choose to request a regulatory conference, the meeting should be held in the NRC
Region I office within 40 days of the date of this letter, and will be open for public observation.
The NRC will issue a public meeting notice and a press release to announce the date and time
of the conference. We encourage you to submit supporting documentation at least one week
prior to the conference in an effort to make the conference more efficient and effective. If you
choose to provide a written response, it should be sent to the NRC within 30 days of the date of
this letter. You should clearly mark the response as Response to Preliminary Greater-than-
Green Finding in Inspection Report No. 05000293/2016011; EA-17-023, and send it to the
U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-
0001, with a copy to the Regional Administrator, Region I, and a copy to the NRC Senior
Resident Inspector at PNPS. You may also elect to accept the finding as characterized in this
letter and the inspection report, in which case the NRC will proceed with its regulatory decision.
However, if you choose not to request a regulatory conference, or to submit a written response,
you will not be allowed to appeal the NRCs final significance determination.
Please contact Arthur Burritt at (610) 337-5069 within 10 days from the issue date of this letter
to notify the NRC of your intentions. If we have not heard from you within 10 days, we will
continue with our significance determination and enforcement decision.
The NRC team also documented nine findings of very low safety significance (Green), seven of
which are violations of NRC requirements, and one Severity Level IV non-cited violation with no
associated finding. The NRC is treating these violations as non-cited violations, consistent with
Section 2.3.2.a of the Enforcement Policy. If you contest the violations or significance of these
non-cited violations, you should provide a response within 30 days of the date of this inspection
report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:
Document Control Desk, Washington, DC 20555-0001; with copies to the Regional
Administrator, Region I; the Director, Office of Enforcement; and the NRC Resident Inspectors
at PNPS. If you disagree with a cross-cutting aspect assignment or a finding not associated
with a regulatory requirement in this report, you should provide a response within 30 days of the
date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear
Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with
copies to the Regional Administrator, Region I; and the NRC Resident Inspectors at PNPS.
J. Dent 5
This letter, its enclosure, and your response (if any) will be made available for public inspection
and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document
Room, in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for
Withholding.
Sincerely,
/RA/
Daniel H. Dorman
Regional Administrator
Docket No. 50-293

License No. DPR-35
Enclosure:
Inspection Report 05000293/2016011
w/Attachments 1 and 2
cc w/encl: Distribution via ListServ

J. Dent 6
SUBJECT: PILGRIM NUCLEAR POWER STATION SUPPLEMENTAL INSPECTION

REPORT (INSPECTION PROCEDURE 95003 PHASE C) 05000293/2016011
AND PRELIMINARY GREATER-THAN-GREEN FINDING DATED MAY 10, 2017
DISTRIBUTION: (via email)

DDorman, RA
DLew, DRA
MScott, DRP
DPelton, DRP
RLorson, DRS
JYerokun, DRS
ABurritt, DRP
LCline, DRP
MDraxton, DRP
JVazquez, DRP
JPfingsten, DRP
ECarfang, DRP, SRI
BPinson, DRP, RI
ACass, DRP, AA
JBowen, RI OEDO
MFerdas, DRP
RidsNrrPMPilgrim Resource
RidsNrrDorlLPL1-1 Resource
ROPReports.Resource
DOCUMENT NAME: G:\DRP\BRANCH5\+++Pilgrim\+++Pilgrim Column 4 Activities\Phase C Inspection Report\Pilgrim 2016011 final.docx

ADAMS ACCESSION NUMBER: ML17129A217
Non-Sensitive Publicly Available

SUNSI Review
Sensitive Non-Publicly Available
OFFICE RI/DRS RI/DRS RI/DRS RIII/DRP RI/DRP

NAME C Bickett F Arner via telecom D Jackson via email E Duncan via email R Clagg via email
DATE 5/5/17 4/28/17 5/5/17 5/3/17 5/4/17
OFFICE HQ/NRR RIV/DRP RI/DRP RI/OE RI/DRP
M Keefe-Forsyth via A Burritt/L Cline for via
NAME J Josey via email B Bickett via email M Scott
email telecom
DATE 5/1/17 5/3/17 5/5/17 5/5/17 5/5/17
OFFICE RI/DRS RI/ORA
NAME R Lorson D Dorman
DATE 5/5/17 5/8/17
OFFICIAL RECORD COPY
1
U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Docket No. 50-293
License No. DPR-35
Report No. 05000293/2016011
Licensee: Entergy Nuclear Operations, Inc. (Entergy)
Facility: Pilgrim Nuclear Power Station (PNPS)
Location: 600 Rocky Hill Road

Plymouth, MA 02360
Dates: November 28, 2016 January 13, 2017
Inspectors: D. Jackson, Team Leader, Branch Chief, Region I

C. Bickett, Assistant Team Leader, Senior Reactor Inspector, Region I
Senior Reactor Analyst

F. Arner, Region I
Problem Identification and Resolution Group

R. Clagg (Lead), Senior Resident Inspector, Calvert Cliffs, Region I
J. Bream, Physical Security Inspector, Region I
D. Dodson, Senior Resident Inspector, Wolf Creek, Region IV
A. Nguyen, Senior Resident Inspector, Palisades, Region III
Leadership, Operations, and Oversight Group

E. Duncan (Lead), Branch Chief, Region III
G. Pick, Senior Reactor Inspector, Region IV
R. Ruiz, Senior Resident Inspector, LaSalle, Region III
A. Sanchez, Senior Resident Inspector, South Texas Project, Region IV
D. Silk, Senior Operations Engineer, Region I (part-time)
Engineering, Maintenance, and Programs Group

J. Josey (Lead), Senior Resident Inspector, Comanche Peak, Region IV
J. Brand, Reactor Inspector, Region I
G. Eatmon, Resident Inspector, North Anna, Region II
K. Miller, Resident Inspector, Farley, Region II
Enclosure
2
S. Elkhiamy, Project Engineer, Region I (training)

J. Schoppy, Senior Reactor Inspector, Region I (part-time)
Safety Culture Assessment Group

M. Keefe-Forsyth (Lead), Human Factors Specialist, Headquarters
L. Micewski, Senior Resident Inspector, Susquehanna, Region I
C. Norton, Senior Resident Inspector, Duane Arnold, Region III
D. Sieracki, Senior Safety Culture Program Manager, Headquarters
N. Staples, Senior Project Inspector, Region II
Approved by: Raymond K. Lorson

Team Manager
Director, Division of Reactor Safety
Enclosure
3
TABLE OF CONTENTS
EXECUTIVE SUMMARY .............................................................................................................. 5

SUMMARY .................................................................................................................................. 13
REPORT DETAILS ..................................................................................................................... 21
1. Performance History.................................................................................................. 21
2. Licensee Site Recovery and Comprehensive Recovery Plan ................................... 21
3. NRC Methodology and Diagnostic Assessment........................................................ 24
3.1 Inspection Objectives ................................................................................................ 24
3.2 Inspection Scope ....................................................................................................... 24
3.3 Inspection Approach.................................................................................................. 24
4. Review of White Safety/Relief Valve (SRV) Finding ................................................. 25
4.1 Background ............................................................................................................... 25
4.2 NRC Inspection Scope .............................................................................................. 25
4.3 Problem Identification ................................................................................................ 27
4.4 Root Cause, Extent of Condition, and Extent of Cause Evaluation ........................... 29
4.5 Corrective Actions Taken and Planned ..................................................................... 40
4.6 Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues ........................ 44
4.7 NRC Inspection Findings........................................................................................... 45
5. Controls for Identifying, Assessing, and Correcting Performance Deficiencies ........ 47
5.1 Corrective Action Program Fundamental Problem .................................................... 47
5.2 Corrective Action Program Accountability and Expectations .................................... 58
5.3 Implementation of the Cause Evaluation Process..................................................... 60
5.4 Work Order Backlog Review for Significant Conditions Adverse to Quality and
Conditions Adverse to Quality ................................................................................... 64
5.5 Implementation of the Trending and Performance Review Process ......................... 65
5.6 Corrective Action Program Implementation: Problem Identification ......................... 66
5.7 Implementation of the Corrective Action Program during Recovery Evaluations ...... 66
5.8 Corrective Action Program Staffing and Training Adequacy ..................................... 67
5.9 Self-Assessment and Benchmarking Activities ......................................................... 69
5.10 Use of Industry Information ....................................................................................... 73
5.11 Comprehensive Recovery Plan Metrics .................................................................... 75
Enclosure
4
6. Reactor Safety Strategic Performance Area ............................................................. 76

Human Performance Key Attribute ...................................................................................... 76
6.1. Decision-Making and Risk-Recognition Fundamental Problem Area ....................... 76
6.2 Procedure Use and Adherence Problem Area .......................................................... 85
6.3 Operability Determinations and Functionality Assessments ..................................... 91
6.4 Operations Department Standards, Site Ownership, and Leadership .................... 102
Procedure Quality Key Attribute ........................................................................................ 105
6.5 Procedure Quality Problem Area............................................................................. 105
6.6 Emergency Preparedness Procedures ................................................................... 113
6.7 Equipment Reliability Problem Area ........................................................................ 113
6.8 Emergency Preparedness Equipment and Facilities ............................................... 123
6.9 Engineering Programs Problem Area...................................................................... 124
6.10 Preventive Maintenance Program ........................................................................... 133
6.11 Large Motor Program .............................................................................................. 135
6.12 Single Point Vulnerabilities ...................................................................................... 138
6.13 Work Management Problem Area ........................................................................... 140
6.14 Industrial Safety Problem Area................................................................................ 143
7. Safety Culture Assessment ..................................................................................... 145
7.1 Nuclear Safety Culture Fundamental Problem ........................................................ 145
7.2 NRC Independent Safety Culture Assessment ....................................................... 162
7.3 Safety Culture and Safety Conscious Work Environment Policies .......................... 176
7.4 Executive Review Board ......................................................................................... 178
7.5 Employee Concerns Program ................................................................................. 179
7.6 Nuclear Safety Culture Monitoring Panel ................................................................ 181
7.7 Nuclear Safety Culture Assessments and Third Party Independent Assessment ... 183
7.8 Other Observations ................................................................................................. 186
8. Performance Deficiency Cause Analysis ................................................................ 186
9. Consideration of IMC 0305 Criteria ......................................................................... 191
10. Licensee-Identified Violations.................................................................................. 192
11. Exit Meeting............................................................................................................. 193
DETAILED RISK EVALUATION ............................................................................................. A1-1
SUPPLEMENTAL INFORMATION ......................................................................................... A2-1
Enclosure
5
EXECUTIVE SUMMARY
Background
Pilgrim Nuclear Power Station (PNPS) transitioned into the Repetitive Degraded Cornerstone
Column (Column 4) of the Reactor Oversight Process Action Matrix as of the first quarter of
2015. This resulted from issuance of a White finding under the Mitigating Systems cornerstone
while PNPS was already in the Degraded Cornerstone Column (Column 3) for more than five
consecutive quarters due to two open White inputs under the Initiating Events cornerstone. In
Inspection Procedure (IP) 95002 Supplemental Inspection Report 05000293/2014008
(ML15026A0691), dated January 26, 2015, the NRC noted that Entergy did not adequately
evaluate the causes and take or plan timely corrective actions to address the issues associated
with a high number of unplanned scrams which occurred in 2013. As a result, the two White
inputs under the Initiating Events cornerstone remained open for greater than five consecutive
quarters, and were in effect when the new White finding was identified during an inspection exit
on March 20, 2015. The NRC subsequently closed the White inputs under the Initiating Events
cornerstone on June 30, 2015, due to successful completion of the IP 95002 follow-up
inspection.
The intent of the IP 95003 inspection was to provide the NRC a comprehensive understanding
of the depth and breadth of safety, organizational, and performance issues at PNPS, and, if
present, the potential for a more serious performance decline. The NRC structured IP 95003
inspection activities at PNPS in a phased approach to ensure that continued operation of the
facility was acceptable until the final phase of the inspection could be completed. The NRC
completed Phase A of IP 95003 in January 2016, which focused on review of longstanding
open corrective actions, Entergys program for classification of adverse versus non-adverse
condition reports (CRs), and Entergys corrective actions to address past NRC violations. The
results of the Phase A inspection are documented in NRC Inspection Report
05000293/2016008, issued February 29, 2016 (ML16060A018). The NRC completed Phase B
of IP 95003 in April 2016, which focused on PNPSs corrective action program performance
since the last biennial problem identification and resolution inspection in August 2015. The
results of the Phase B inspection are documented in NRC Inspection Report
05000293/2016009, issued May 20, 2016 (ML16144A027).
This inspection report documents the results of Phase C of IP 95003, which satisfies the
remaining IP 95003 inspection requirements, as well as review of the White finding in the
Mitigating Systems cornerstone related to safety/relief valve (SRV) performance at the station.
The NRC used the results of this inspection to determine whether continued operation of the
facility was acceptable and whether additional regulatory actions were necessary to arrest
declining plant performance. The NRC first defined the specific scope for this inspection in the
2015 PNPS mid-cycle assessment letter, dated September 1, 2015 (ML15243A259). Based on
persistent corrective action program weaknesses that resulted in PNPSs entry into Column 4,
this IP 95003 inspection focused on the corrective action program (IP 95003 Section 02.02) and
safety culture assessment (IP 95003 Sections 02.07 02.09). Based on evaluation of the
inputs into the Action Matrix, the reactor safety strategic performance area of the inspection
focused on the key attributes of human performance (IP 95003 Section 02.03c), procedure
quality (IP 95003 Section 02.03d), and equipment performance (IP 95003 Section 02.03e).
1
Designation in parentheses refers to an Agencywide Documents Access and Management System
(ADAMS) accession number. Documents referenced in this report are publicly available using the
accession number in ADAMS.
Enclosure
6
Overall Assessment and Conclusions
The NRC determined that programs and processes at PNPS adequately support nuclear safety
and that PNPS should remain in Column 4. Inspection Manual Chapter 0305, Reactor
Oversight Assessment Process, Section 10.02e, provides examples of unacceptable
performance which represent situations in which the NRC lacks reasonable assurance that the
licensee can or will conduct its activities to ensure protection of the public health and safety.
With respect to these examples, the NRC has not identified: 1) multiple escalated violations of
PNPSs license, technical specifications, regulations, or orders; 2) multiple safety-significant
examples where the facility was determined to be outside of its design basis; or 3) a pattern of
failure by Entergy management to effectively address previous significant concerns to prevent
recurrence. While gaps in performance were identified during this inspection, the NRC
determined that the above examples of unacceptable performance were not met. In particular,
the NRC noted that licensed operators demonstrated, both in the control room and in the
simulator, the ability to effectively respond to events to place the reactor in a safe condition,
consistent with their licensed responsibilities. The NRC also observed some improvement in
corrective action program performance and a reduction in the number of operational events that
resulted in a reactor scram. However, based on the results of this inspection, as well as
consideration of recent events at the station, the NRC team identified areas that warrant
Entergys immediate attention. Primarily, revisions are needed to the PNPS Comprehensive
Recovery Plan to ensure that performance improvements will be achieved and sustained.
Specifically:
Adjustments to corrective actions or compensatory measures to assure that the

corrective actions to preclude repetition (CAPRs) documented in the Comprehensive
Recovery Plan will drive sustainable performance improvement;
Inclusion of corrective actions to address the significant weaknesses identified during

review of the root cause evaluation for the White SRV finding;
A description of how Entergy is planning to address gaps identified by Phase C of the

IP 95003 inspection associated with the rigor with which senior licensed operators
assure the plant is operated within its design bases (including operability determinations,
technical specification knowledge, and questioning attitude);
A review and analysis of the effectiveness of Entergys implementation of subject matter

experts and mentors, including any potential expanded scope needed to drive sustained
management performance improvement; and
A description of how Entergy is addressing gaps in procedure use and adherence, which
have resulted in recent events2 at PNPS.
Additionally, Entergy needs to implement current Comprehensive Recovery Plan actions in a

more rigorous and thoughtful manner to achieve substantial and sustainable performance
improvement.
2
Event notification reports 52643 (March 27, 2017) and 52655 (March 31, 2017), available at
https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2017
Enclosure
7
This report documents one finding that the NRC team has preliminarily determined to be greater
than very low safety significance (i.e., greater than Green). The NRC team determined that
Entergy did not account for potential new failure mechanisms on a new component, a relief
valve, on the right angle drive for the A emergency diesel generator radiator blower fan. As a
result, Entergy did not consider the need to periodically monitor or maintain the valve, which
subsequently failed, resulting in inoperability of the A emergency diesel generator (Section
6.7.4). The NRC team also identified nine findings of very low safety significance (Green),
seven of which are violations of NRC requirements, and one Severity Level IV non-cited
violation with no associated finding. Additionally, two licensee-identified violations of very low
safety significance are documented in this report.
PNPS Site Recovery Process (Section 2)
Entergy conducted multiple assessments as part of their diagnostic recovery process. The
results of these assessments were binned into broader categories, and ultimately analyzed to
identify the major problem areas driving the performance issues at PNPS. The problems that
caused other problems (i.e., drivers) were designated as fundamental problems. Problems
that were caused by the fundamental problems (i.e., driven) were designated as problem
areas. Entergy performed either a root or apparent cause evaluation for each of these areas.
IP 95001: SRV White Finding (Section 4)
The NRC team determined that the collective issues associated with the root cause
methodologies in root cause evaluation CR-PNP-2016-01621 represented a significant
weakness, such that the objectives of IP 95001 could not be satisfied for this issue. Most
notably, the incorrect conclusions and assumptions related to the adequacy of information in
CR-PNP-2013-00825, originally written for A SRV operation in 2013, adversely impacted four
of the cause evaluation methodologies used in root cause evaluation CR-PNP-2016-01621.
Specifically, the details that were provided were adequate for an appropriately rigorous
operability determination review to identify that SRV A did not open. This ultimately resulted in
Entergy inappropriately assessing the impact of shift manager review rigor, and any associated
causal factors, in the root cause evaluation. Entergy documented this issue and specific issues
identified during this portion of the inspection in CR-PNP-2017-00363 and CR-PNP-2017-
00828. The NRC team documented a finding associated with this issue for failure to identify all
root causes of a significant condition adverse to quality. Specifically, Entergy did not establish
adequate measures to assure that the cause of a significant condition adverse to quality,
inadequate shift manager operability determination rigor and its associated causes, were
determined and corrective action taken to preclude repetition (Section 4.7).
Corrective Action Program Fundamental Problem (Section 5)
The NRC team concluded that Entergys identification of the corrective action program as a
fundamental problem was appropriate. The team determined that the identified direct cause,
root cause, and contributing causes in CR-PNP-2016-00716 were generally reasonable and
supportable. However, the NRC team noted that the root cause focused on the station senior
leadership and failed to adequately address the role that lower-level leaders had in the
implementation of the day-to-day prioritization and resolution of corrective action program items.
The team determined that the definition of leaders associated with the root cause was too
narrow and failed to recognize that department performance improvement coordinators had a
significant leadership role in the implementation and assessment of the corrective action
program. The team concluded that CAPR-1 and CAPR-2, as they were written and
Enclosure
8
implemented, were not adequate to correct the root cause and preclude repetition of the
fundamental problem because the CAPRs did not include a systematic or structured approach
to coaching/mentoring to reach all station personnel with leadership responsibilities in the
implementation of the corrective action program. The NRC team documented a finding related
to this issue in Section 5.1.4.
Decision-Making/Risk-Recognition Fundamental Problem (Section 6.1)
The NRC team concluded that Entergys identification of decision making/risk recognition as a
fundamental problem was appropriate. The team further concluded that the root and
contributing causes were appropriately identified by Entergy and that the corrective actions
developed by the station to address the root and contributing causes were appropriate. Of
those corrective actions sampled, all reviewed were being adequately implemented, though in
some cases, would have benefitted from more rigorous and consistent implementation. The
NRC teams observations suggested that the new standards and the 1.3.142, PNPS Risk
Review and Disposition, process, as delineated by CAPR-1, were not yet consistently being
demonstrated by all levels of station leaders. Additionally, one of the key actions in CAPR-1
involved the use of Targeted Performance Improvement Plans to change and shape behaviors,
reinforce expectations and standards, and achieve the desired results. The NRC team
determined that the Targeted Performance Improvement Plans were inadequate and
documented a finding related to this issue in Section 7.1.4.
With regards to augmentation of staff with subject matter experts, the NRC team concluded that
the subject matter experts appeared to have a positive impact on the improvement and recovery
efforts of the station. The nature of the subject matter experts interactions with PNPS leaders
was observed to be one of a consultation/recommendation based relationship, so the subject
matter experts had no direct decision-making or line management authority, other than the
ability to generate CRs. In the interactions observed by the NRC team, the PNPS senior
leaders were generally receptive to the feedback from the subject matter experts and took
actions to address items identified by the subject matter experts. However, based on interviews
and a review of current open corrective action program items generated by the subject matter
experts, the NRC team noted resistance to the improvement recommendations of the subject
matter experts by some station managers. Additionally, the NRC team noted that the subject
matter experts had recently shifted their approach to a more direct method of writing CRs for
identified issues, versus their previous method of attempting to first influence the station staff to
self-identify the issue, as a more effective way of impacting changes in station behavior. The
NRC team also reviewed a sample of the reports that documented the results of the
observations performed by the subject matter experts. The NRC team concluded that these
reports effectively presented the results of the subject matter experts observations in a frank
and open manner, such that lessons could be learned and improvements realized. The NRC
team also noted that, as of the end of this inspection, the decision making/risk recognition
subject matter experts were instructed by the Site Vice President to focus more attention directly
on mentoring and coaching the operations shift managers as an additional means of improving
operations department decisions and behaviors.
Nuclear Safety Culture Fundamental Problem (Section 7.1)
The NRC team concluded that Entergys identification of nuclear safety culture as a
fundamental problem was appropriate. The NRC team determined that the multi-year gradual
performance decline occurred, in part, due to declines in nuclear safety culture that went
unrecognized and unaddressed. Performance monitoring tools and management responses
Enclosure
9
were ineffective in recognizing and addressing the decline until they began to impact
performance. While nuclear safety remained a priority, actions to balance competing priorities,
manage problems, and prioritize workload resulted in reduced safety margins.
Overall, the team noted significant weaknesses in development and implementation of the
Targeted Performance Improvement Plans (CAPR-1A/B), including unclear alignment between
the causal factors and items contained in the plans, inappropriate parallel implementation of the
plans, insufficient duration of corrective actions for improvement of behaviors, generic versus
specific counseling to address adverse behaviors, success criteria that would not be expected
to result in substantial performance improvement at the station, and numerous administrative
issues that impacted usefulness or credibility of the process. The NRC team concluded that
these significant implementation weaknesses severely limited the overall effectiveness of the
CAPR.
Entergy implemented a nuclear safety culture observation process using an external Nuclear
Safety Culture Advocate. The NRC team concluded that the scope and format of the external
nuclear safety culture observation process was an appropriate improvement and accountability
tool and that the Nuclear Safety Culture Advocate role was being effectively implemented.
The NRC team did note examples of corrective actions in the Comprehensive Recovery Plan
had been changed by the station such that the action would match what Entergy actually
accomplished, versus what was intended by the original action. For example, one action
required that Entergy implement a communications plan for all full-time site personnel and
supplemental personnel that will allow PNPS to more fully understand the traits of a healthy
nuclear safety culture and how nuclear safety culture influences nuclear safety performance.
This was originally a one-time interim action that could be closed when 90 percent of the target
population received the communication. The NRC team reviewed the closure of this action and
identified that no objective evidence was included that demonstrated that 90 percent of the
target population had received the communication. Subsequently, the NRC team determined
that the Action Closure Review Board had previously identified that PNPS failed to provide
documented evidence that 90 percent of the targeted population had received the
communications. To address this issue, Entergy revised the corrective action to align with what
had been accomplished, with a basis that the action as it was originally written was not realistic
or necessary. Following this change, the Action Closure Review Board approved the closure of
the corrective action. The NRC team reviewed this action and concluded that the relatively
small number of employees that received the training (estimated at less than 50 percent)
adversely impacted the effectiveness of the corrective actions. However, the NRC team
recognized that redundancy and defense-in-depth provided by other more substantive
corrective actions, such as the gap refresher training, mitigated the significance of this issue.
The NRC team noted that the nuclear safety culture root cause evaluation determined plant
performance issues were exacerbated by the cumulative impact of staffing reduction initiatives.
Resource issues were identified in other cause evaluations conducted as part of Entergys
recovery evaluations, including those related to the problem areas of work management,
engineering programs, and equipment reliability. To address this issue, corrective actions were
created to establish and implement procedural guidance for an Integrated Strategic Workforce
Plan to ensure the appropriate level of staffing was maintained to support station goals and
objectives. The team reviewed this plan and determined that, if properly implemented, it had
the potential to be an effective tool for workforce planning.
Enclosure
10
NRCs Graded Safety Culture Assessment (Section 7.2)
The NRC team assessed PNPSs safety culture by conducting focus groups, interviews,
behavioral observations, and document reviews. The NRC team conducted a total of 20 focus
groups and 29 individual interviews which included questions related to all 10 traits that
comprise a safety culture. In all, the NRC team interviewed 188 staff, supervisors, and
managers, representing about 30 percent of the workforce at PNPS. In general, the NRC
teams independent safety culture assessment confirmed the results of PNPSs Third Party
Nuclear Safety Culture Assessment, which noted weaknesses in most areas. The general
consensus among the focus group and interview participants was that safety culture at PNPS
was much improved. Most participants perceived that there had been a marked change in
leaderships focus on safety over production over the past year or so. Participants noted that
there had been a new emphasis on procedure use and adherence and procedure quality, as
well as improvements in conservative decision-making. Additionally, personnel felt that they
were able to trust management up through the Site Vice President.
Despite the improved safety culture, PNPS was still challenged with translating the safety
culture beliefs into repeatable, sustainable safety culture behaviors. The NRC team determined
that some station personnel, including operators, technicians, supervisors, and management,
were challenged to routinely exhibit site standards and expectations when performing normal
duties and responsibilities in areas such as conservative decision-making, work practices, and
procedure use and adherence. The NRC team concluded that this may be due to a number of
factors, including the planned permanent shutdown of PNPS in 2019, the lack of effective
benchmarking to understand what current industry standards consist of relative to issues in the
organization, as well as the time it typically takes to change the safety culture of an
organization.
Station personnel did note some challenges during the focus groups and individual interviews.
Most personnel at all levels indicated that resource challenges continued to impact their ability
to accomplish work. Though most staff indicated that the corrective action program had
improved, some expressed concern that when contractor support was no longer at the station,
PNPS would revert to past behaviors. Some staff also perceived that with regards to
accountability, supervisors and managers were not held to the same standard as non-
supervisory employees. Some personnel noted weaknesses in the work planning and
scheduling processes, especially related to emergent work.
Nearly all personnel interviewed and in focus groups stated that they felt free to raise nuclear
safety concerns through many avenues, including their supervisors, the corrective action
program, the Employee Concerns Program, and the NRC. However, the team noted that
concerns related to one event could be precursors to a potential chilled work environment in the
radiation protection department (Section 7.8). Additionally, the NRC team noted some general
frustration in the security department related to areas such as use of the corrective action
program, resources, respectful work environment, and consideration during work planning.
Despite these issues, the NRC team determined that employees of the security department
would still raise nuclear safety concerns through the available avenues.
Finally, the NRC team noted some weaknesses in implementation of the Executive Review
Board, Employee Concerns Program, and the Nuclear Safety Culture Monitoring Panel.
Examples include an issue that was not evaluated by the Executive Review Board even though
Enclosure
11
it was required by Entergy procedure, issues with Employee Concerns Program Coordinator
qualifications, and rigor associated with review of items at the Nuclear Safety Culture Monitoring
Panel.
Performance Deficiency Cause Analysis (Section 8)
In general, the NRC team agreed with the fundamental problems and problem areas identified
during Entergys recovery evaluations. However, the NRC team noted the following areas of
concern during the inspection, which will need to be addressed by Entergy:
Weaknesses in Adequacy and/or Implementation of CAPRs. In general, the NRC team

noted that Entergy exhibited weaknesses in the adequacy and/or implementation of the
CAPRs for the root causes reviewed during this inspection. This included the CAPRs for
the corrective action program root cause evaluation, the feedwater regulating valve
failure root cause evaluation, and the nuclear safety culture root cause evaluation.
Operations Department Standards. The NRC team concluded that in general, the
operations staff at PNPS operated the plant safely, within design basis limits, and in a
manner granted to them in their license. However, numerous examples observed by
both the NRC team and the resident inspector staff indicated a lack of formality,
appropriate technical specification usage, and attention to detail for implementation of
administrative programs, which could represent precursors to a further decline in
performance. The NRC team also determined that the operations department had not
consistently demonstrated strong site ownership, leadership, and high standards of
performance. The NRC team determined that additional action will be needed by
Entergy to fully define the extent of the weaknesses related to operator standards at
PNPS, as well as develop appropriate corrective actions to address those weaknesses.
Implementation of Subject Matter Experts at PNPS. Based on a review of the root

causes for the fundamental problems, the NRC team concluded that weaknesses in
PNPS leadership standards and behaviors were drivers for Column 4 performance at the
station. This is also supported by the results of the PNPS Third Party Nuclear Safety
Culture Assessment, which indicated that the senior leadership team had not been
consistently engaged in demonstrating and demanding higher levels and standards of
performance from the site. Given the weaknesses identified related to the CAPRs for
the fundamental problems, the NRC team concluded that the subject matter experts and
mentors currently embedded in the PNPS organization are playing and will need to
continue to play a key role in improving and sustaining positive changes in safety culture
and performance at the station. This is especially true since it is commonly accepted
that safety culture takes on the order of years to change, and it is evident, based on the
observations and findings documented by the team, as well as the NRC independent
safety culture assessment, that improved standards have not yet taken hold across the
entire organization.
Overall, the NRC team concluded that the subject matter experts and mentors were
generally having a positive impact on recovery efforts at PNPS. However, the NRC
team noted that with the exception of the lead corrective action program subject matter
expert and the Nuclear Safety Culture Advocate, positions to which PNPS is committed
to the current end of plant operations, the station has the flexibility to remove the subject
matter experts and mentors following a successful effectiveness review of the related
Enclosure
12
area. Also of note, the lead corrective action program subject matter expert is only
required to provide a minimum of one weekly on-site visit per month.
Given this situation, the NRC team determined that more robust and comprehensive
action is prudent related to implementation of the subject matter experts and mentors at
PNPS. At a minimum, this would include more significant time spent at the site,
objective evidence showing positive, timely action taken in response to items identified in
the subject matter expert status reports, and addition of subject matter experts and/or
mentors at strategic levels in the operations department organization. Implementation of
subject matter experts and mentors should continue until a positive change in safety
culture is sustained and verified by NRC inspection. Additionally, more robust and
comprehensive action is needed related to implementation of the Targeted Performance
Improvement Plans (Section 7.1.4), as this action, in concert with the subject matter
experts and mentors, would be the foundation for improving the safety culture at PNPS.
Enclosure
13
SUMMARY
Inspection Report 05000293/2016011; 11/28/2016 01/13/2017; Pilgrim Nuclear Power Station;

Supplemental Inspection IP 95003.
The inspection activities described in this report were performed by a team of 23 inspectors
representing all of the NRCs regional offices, as well as the headquarters office. The NRC
team identified one finding and apparent violation that has been determined to be preliminarily
greater than very low safety significance (i.e., preliminary greater than Green). The team also
identified nine findings of very low safety significance (Green), seven of which are violations of
NRC requirements, and one Severity Level IV non-cited violation. Additionally, two licensee-
identified violations of very low safety significance are documented in this report.
The significance of inspection findings is indicated by their color (i.e., greater than Green, or
Green, White, Yellow, Red), and determined using Inspection Manual Chapter (IMC) 0609,
Significance Determination Process, dated April 29, 2015. Cross-cutting aspects are
determined using IMC 0310, Aspects Within the Cross-Cutting Areas, dated December 4,
2014. All violations of NRC requirements are dispositioned in accordance with the NRCs
Enforcement Policy, dated November 1, 2016. The NRCs program for overseeing the safe
operation of commercial nuclear power reactors is described in NUREG-1649, Reactor
Oversight Process, Revision 6.
Cornerstone: Initiating Events
Green. The NRC team identified a Green finding because Entergy did not issue appropriate
CAPRs in accordance with Entergy procedure EN-LI-102, Corrective Action Process,
Revision 28. Specifically, Entergy did not issue adequate CAPRs associated with Root
Cause 1 of the feedwater regulating valve failure in September 2016 that resulted in a
manual scram. As a result of the NRC teams questions, Entergy issued procedure 1.13.2,
Vendor and Technical Information Reviews, Revision 0, as continuous use to ensure that
planners will always have the checklist in-hand when planning work to ensure that
appropriate vendor technical information is always included in applicable work instructions.
Entergy entered the NRC teams concerns in the corrective action program as CR-PNP-
2017-00687 and CR-PNP-2017-00936.
The performance deficiency was more than minor because it is associated with the
equipment performance attribute of the Initiating Events cornerstone and if left uncorrected,
the performance deficiency would have the potential to lead to a more significant safety
concern. Specifically, if left uncorrected, the performance deficiency could have the
potential to result in repetition of a significant condition adverse to quality, loss of control of
feedwater regulating valve 642A and a manual scram. The NRC team evaluated the finding
using Exhibit 1, Initiating Events Screening Questions, of IMC 0609, Appendix A,
Significance Determination Process for Findings At-Power, and determined this finding did
not cause a reactor trip or the loss of mitigation equipment relied upon to transition the plant
from the onset of a trip to a stable shutdown condition. Therefore, the NRC team
determined the finding was of very low safety significance (Green). The NRC team
determined that the finding had a cross-cutting aspect in the area of Human Performance,
Procedure Adherence, because individuals did not follow processes, procedures, and work
instructions. Specifically, Entergy did not follow procedure EN-LI-102, which provides the
station standards for crafting a corrective action and states, in part, that the corrective action
Enclosure
14
descriptions must be worded to ensure that the adverse condition or cause/factor is

addressed [H.8]. (Section 5.3.3)
Cornerstone: Mitigating Systems
Green. The NRC team identified a Green non-cited violation of Title 10 of the Code of
Federal Regulations (10 CFR) Part 50, Appendix B, Criterion XVI, Corrective Action,
because Entergy did not adequately determine all root causes associated with a significant
condition adverse to quality related to the failure to identify, evaluate, and correct the A
SRVs failure to open upon manual actuation during a plant cooldown on February 9, 2013.
Specifically, Entergy did not establish adequate measures to assure that the cause of a
significant condition adverse to quality, inadequate shift manager operability determination
rigor and its associated causes, were adequately determined and corrective action taken to
preclude repetition. Entergys immediate corrective actions included planning to conduct
operations management face-to-face conversations with shift manager qualified individuals
to reinforce the shift managers responsibility for operability and functionality determination
accuracy and rigor. Entergy entered this issue into the corrective action program as CR-
PNP-2017-00363 and CR-PNP-2017-00828.
equipment performance attribute of the Mitigating Systems cornerstone and if left
uncorrected, the performance deficiency would have the potential to lead to a more
significant safety concern. Specifically, if left uncorrected, the performance deficiency could
have the potential to result in repetition of a failure to identify, evaluate, and correct an
SRVs failure to open or a similar significant condition adverse to quality. The NRC team
evaluated the finding using Exhibit 2, Mitigating Systems Screening Questions, of IMC
0609, Appendix A, Significance Determination Process for Findings At-Power, and
determined this finding did not affect the design or qualification of a mitigating structure,
system, or component; represent a loss of system and/or function; involve an actual loss of
function of at least a single train or two separate safety systems for greater than its technical
specification-allowed outage time; or represent an actual loss of function of one or more
non-technical specification trains of equipment designated as high safety-significant.
Therefore, the NRC team determined the finding was of very low safety significance
(Green). The NRC team determined that the finding had a cross-cutting aspect in the area
of Human Performance, Avoid Complacency, because individuals did not recognize and
plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting
successful outcomes. Specifically, Entergy incorrectly assumed that CR-PNP-2013-00825
contained inadequate information to determine that the A SRV had not opened, and this
assumption ultimately impacted the root cause results documented in CR-PNP-2016-01621
[H.12]. (Section 4.7)
Green. The NRC team identified a Green non-cited violation of 10 CFR Part 50, Appendix
B, Criterion XVI, Corrective Action, because Entergy did not implement CAPRs for a
significant condition adverse to quality identified in root cause evaluation CR-PNP-2016-
00716, Implementation of the Corrective Action Program, Revision 2. Specifically, the
team identified that CAPRs for Entergys continued weaknesses in the implementation of the
corrective action program were inadequate. Entergy entered this issue into their corrective
action program for further evaluation as CR-PNP-2017-00053, CR-PNP-2017-00410, and
CR-PNP-2017-01134.
Enclosure
15
The performance deficiency was more than minor because if left uncorrected, it had the
potential to lead to a more significant safety concern. Specifically, the failure to preclude
repetition of this significant condition adverse to quality could result in continuing
weaknesses in implementation of the corrective action program, which was designated as a
fundamental problem, and thus a contributing factor for PNPS Column 4 performance.
Additionally, weaknesses with corrective action program implementation could result in
equipment issues where operability is not maintained. The NRC team evaluated the finding
using Exhibit 2, Mitigating Systems Screening Questions, of IMC 0609, Appendix A,
not affect the design or qualification of a mitigating structure, system, or component;
represent a loss of system and/or function; involve an actual loss of function of at least a
single train or two separate safety systems for greater than its technical specification-
allowed outage time; or represent an actual loss of function of one or more non-technical
specification trains of equipment designated as high safety-significant. Therefore, the NRC
team determined the finding was of very low safety significance (Green). The NRC team
determined that the finding had a cross-cutting aspect in the area of Human Performance,
Procedure Adherence, because individuals did not follow processes, procedures, and work
instructions. Specifically, Entergy did not follow procedure EN-LI-102, which provides the
station standards for crafting a corrective action and states, in part, that the corrective action
addressed [H.8]. (Section 5.1.4)
B, Criterion V, Instructions, Procedures, and Drawings. Specifically, the NRC team
identified a programmatic issue because in some cases, Entergy did not enter the
operability determination process when appropriate, and, when the process was entered,
did not adequately document the basis for operability, in accordance with Procedure EN-
OP-104, Operability Determination Process, Revision 11. In each of the examples
discussed, though the basis for operability was not adequate, all components were
determined to be operable upon further evaluation. Entergy entered this issue into their
corrective action program as CR-PNP-2017-00626.
The performance deficiency was more than minor because if left uncorrected, could lead to
a more significant safety issue. Specifically, the failure to enter and document a basis for
operability could lead to not recognizing inoperable safety-related equipment, and place the
reactor at a higher risk of core damage in a design basis accident. The NRC team
(Green). This finding had a cross-cutting aspect in the area of Human Performance,
Teamwork. Specifically, the operations and engineering departments did not demonstrate a
strong sense of collaboration and cooperation with respect to holding each other
accountable when performing operability determinations to ensure nuclear safety is
maintained [H.4]. (Section 6.3.4)
Enclosure
16
B, Criterion XVI, Corrective Action, because Entergy implemented inadequate corrective
actions to address the procedure quality issues identified in CR-PNP-2016-02058.
Specifically, Entergy inappropriately limited their corrective actions to those procedures that
increased integrated risk above normal, and did not include other types of safety-related
procedures that did not meet their procedure quality standards and resulted in procedure
quality being a problem area. Entergy entered this issue into their corrective action program
for further evaluation as CR-PNP-2017-00400.
The performance deficiency was more than minor because it affected the procedure quality
attribute of the Mitigating Systems cornerstone, and affected the cornerstone objective to
ensure the availability, reliability, and capability of systems that respond to initiating events
to prevent undesirable consequences (i.e., core damage). Entergy limited corrective actions
to procedures that increased integrated risk above normal or trip sensitive and failed to
include other procedures associated with safety-related components that reflected the
broader population reviewed during the collective evaluation. The NRC team evaluated the
finding using Exhibit 2, Mitigating Systems Screening Questions, of IMC 0609, Appendix A,
team determined the finding was of very low safety significance (Green). The NRC team
determined that this finding had a cross-cutting aspect related to Human Performance,
Resources, because the leaders failed to ensure that personnel, equipment, procedures,
and other resources are available and adequate to support nuclear safety. Specifically,
based on available resources, Entergy chose to limit the scope of safety-related procedures
being revised to only those that resulted in high integrated risk or were trip sensitive [H.1].
(Section 6.5.4)
Preliminary Greater than Green. The NRC team identified a preliminary greater than Green
finding and apparent violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control,
associated with Entergys failure to ensure that design changes were subject to design
control measures commensurate with those applied to the original design and were
approved by the designated responsible organization. Specifically, Entergy received a new
style right angle drive for the A emergency diesel generator radiator blower fan from a
vendor but failed to adequately review the differences in the design of the drives to identify
potential new failure mechanisms for the part or the need for related preventive measures.
Entergy entered this issue into the corrective action program as CR-PNP-2016-07443.
The performance deficiency was more than minor because it was associated with the design
control attribute of the Mitigating Systems cornerstone, and affected the associated
cornerstone objective to ensure availability, reliability, and capability of systems that respond
to initiating events to prevent undesirable consequences. In accordance with IMC 0609.04,
Initial Characterization of Findings, and Exhibit 2 of IMC 0609, Appendix A, The
Significance Determination Process for Findings At-Power, the team screened the finding
for safety significance and determined that a detailed risk evaluation was required based on
the A emergency diesel generator being inoperable for greater than the technical
specification allowed outage time.
Enclosure
17
Region I senior reactor analysts performed a detailed risk evaluation. The finding was
preliminarily determined to be of greater than very low safety significance (greater than
Green). The risk important sequences were dominated by external fire risk. Specifically, a
postulated fire in the B 4 kilovolt (KV) switchgear room with a consequential loss of the unit
auxiliary generator power supply, non-recoverable loss of off-site power (LOOP) to both
safety buses A5 and A6, loss of the B emergency diesel generator with the conditional
failure of the A emergency diesel generator, along with the loss of bus A8 feed (from the
shutdown transformer or station blackout (SBO) diesel generator) to safety buses A5 and
A6. The internal event risk was dominated by weather related LOOPs, failure of the A
emergency diesel generator, with failure of the B emergency diesel generator and SBO
diesel generator to run, along with failure to recover offsite power or the emergency diesel
generators. See Attachment 1, A Emergency Diesel Generator Cooling Water System
Degradation Detailed Risk Evaluation, for a detailed review of the quantitative criteria
considered in the preliminary risk determination.
The NRC team did not assign a cross-cutting aspect to this finding because the
performance deficiency occurred in May 2000. Entergys program has undergone changes
since May 2000, and the NRC team did not identify any recent examples of this
performance deficiency. Other aspects of Entergys performance related to this issue are
further discussed in Sections 5.10.3 and 6.3.4. (Section 6.7.4.1)
Green. The NRC team identified a Green non-cited violation of 10 CFR 50.65(a)(2),
Requirements for monitoring the effectiveness of maintenance at nuclear power plants.
Specifically, Entergy did not demonstrate that the performance of 18 maintenance rule
scoped components was effectively controlled through the performance of appropriate
preventive maintenance, and did not establish goals and monitoring in accordance with
10 CFR 50.65(a)(1). Entergys immediate corrective action was to initiate a CR to evaluate
moving the affected systems to 10 CFR 50.65(a)(1) monitoring requirements. Entergy
entered this issue in the corrective action program as CR-PNP-2017-00401.
The performance deficiency was more than minor because it was associated with the
equipment performance attribute of the Mitigating Systems cornerstone and affected the
cornerstone objective to ensure availability, reliability, and capability of systems that respond
to initiating events to prevent undesirable consequences. Specifically, Entergy failed to
demonstrate that the performance of the 18 maintenance rule scoped components was
being effectively controlled through the performance of appropriate preventive maintenance
which adversely impacts the reliability of those systems. The NRC team evaluated the
finding using Exhibit 2, Mitigating Systems Screening Questions, of IMC 0609, Appendix A,
team determined the finding was of very low safety significance (Green). The finding had a
cross-cutting aspect in the area of Problem Identification and Resolution, Evaluation, in that
Entergy failed to thoroughly evaluate and ensure that resolution of the identified issue,
maintenance not being performed on maintenance rule scoped components, included
reclassifying the components as necessary. Specifically, Entergy failed to demonstrate that
the performance of 18 maintenance rule scoped components was effectively controlled
Enclosure
18
through the performance of appropriate preventive maintenance, or through performance

goals and monitoring. [P.2]. (Section 6.9.4.1)
B, Criterion XVI, Corrective Action, because Entergy did not take timely corrective action
for a previously identified condition adverse to quality. Specifically, Entergy failed to
adequately resolve, through repair or adequate evaluation, gasket leakage on the B
residual heat removal heat exchanger, which resulted in continued degradation and leakage
for the heat exchanger gasket. Entergy did not consider this leakage as a degraded
condition, with the potential to impact both the operability of the residual heat removal
system, and PNPSs licensing basis with regards to leakage of a closed loop system outside
of containment. After the NRC team raised the issue, Entergy performed an operability
determination that established a reasonable expectation of operability pending
implementation of corrective actions. Entergy entered this issue into their corrective action
program as CR-PNP-2016-09725.
equipment performance attribute of the Mitigating Systems cornerstone and adversely
affected the cornerstone objective to ensure availability, reliability, and capability of systems
that respond to initiating events to prevent undesirable consequences. Specifically, the
failure to correct identified gasket leakage resulted in continued degradation and leakage of
the heat exchanger gasket. The NRC team evaluated the finding using Exhibit 2, Mitigating
Systems Screening Questions, of IMC 0609, Appendix A, Significance Determination
Process for Findings At-Power, and determined this finding did not affect the design or
qualification of a mitigating structure, system, or component; represent a loss of system
and/or function; involve an actual loss of function of at least a single train or two separate
safety systems for greater than its technical specification-allowed outage time; or represent
an actual loss of function of one or more non-technical specification trains of equipment
designated as high safety-significant. Therefore, the NRC team determined the finding was
of very low safety significance (Green). The finding had a cross-cutting aspect in Human
Performance, Conservative Bias, because Entergy failed to use decision making practices
that emphasize prudent choices over those that are simply allowable [H.14]. (Section
6.9.4.3)
Green. The NRC team identified a Green finding because Entergy did not adequately
develop and implement a CAPR of a root cause related to a Category A CR, as required by
Entergy Procedure EN-LI-102, Corrective Action Program. Specifically, Entergy did not
adequately develop and implement the Targeted Performance Improvement Plans, which
were designated as a CAPR for the root cause for the Nuclear Safety Culture Fundamental
Problem. Entergy documented this issue in the corrective action program for further
evaluation as CR-PNP-2017-00406.
The performance deficiency was more than minor because if left uncorrected, it could lead
to a more significant safety concern. Specifically, inadequate implementation of the
Targeted Performance Improvement Plans could result in recurrence of a culture in which
leaders are not holding themselves and their subordinates accountable to high standards of
performance, resulting in continuing performance issues at the station. The NRC team
Enclosure
19
(Green). This finding had a cross-cutting aspect in the area of Human Resources, Change
Management, because leaders did not use a systematic process for evaluating and
implementing change so that nuclear safety remains the overriding priority. In this case,
PNPS leaders did not apply sufficient rigor in development and implementation of the
Targeted Performance Improvement Plans such that they would be an adequate method to
drive and sustain positive changes in the stations safety culture [H.3]. (Section 7.1.4)
Cornerstone: Barrier Integrity
B, Criterion XVI, Corrective Action, associated with Entergys failure to correct a condition
adverse to quality affecting safety-related equipment. Specifically, during a previous NRC
inspection in August 2016, inspectors identified numerous locations in the drywell where
non-seismic equipment was either in contact, or close proximity, with the drywell liner and
had caused damage. Entergy initiated CRs and performed an operability evaluation for the
identified issues. However, following a review of these CRs, the NRC team determined that
Entergy failed to take corrective actions to address the condition adverse to quality. Entergy
entered this issue into the corrective action program as CR-PNP-2016-09346 and CR-PNP-
2016-09377 to perform an extent of condition review, secure the loose grating that had
caused damage to the liner, and evaluate the need for a clearance criteria between
components such as floor grating and support structures and the containment liner.
configuration control attribute of the Barrier Integrity cornerstone and affected the
cornerstone objective to provide reasonable assurance that physical design barriers (fuel
cladding, reactor coolant system, and containment) protect the public from radionuclide
releases caused by accidents or events. Using IMC 0609, Appendix A, The
Significance Determination Process for Findings At-Power, Exhibit 3, Barrier Integrity
Screening Questions, the NRC team determined that this finding was of very low safety
significance (Green) because the finding did not represent an actual open pathway in the
physical integrity of reactor containment (valves, airlocks, etc.), containment isolation
system (logic and instrumentation), and heat removal components. This finding had a
cross-cutting aspect in the area of Problem Identification and Resolution, Evaluation,
because the engineering evaluation of the degraded condition identified by the
inspectors did not thoroughly evaluate the containment liner issues to ensure that
resolutions address causes and extents of condition commensurate with their safety
significance [P.2]. (Section 6.9.4.2)
Other Findings
Severity Level IV. The NRC team identified a Severity Level IV non-cited violation of 10
CFR 50.73, Licensee Event Report System, associated with Entergys failure to submit a
licensee event report within 60 days following discovery of an event meeting the reportability
criteria. Specifically, on September 28, 2016, Entergy identified the A emergency diesel
generator was inoperable. The NRC team determined that the condition was prohibited by
technical specifications and the inoperability of the A emergency diesel generator existed
for a period of time longer than allowed by Technical Specification 3.5.F, Core and
Enclosure
20
Containment Cooling Systems. This was also reportable as a safety system functional
failure. Entergy entered this issue into the corrective action program as CR-PNP-2016-
09552.
Because this performance deficiency had the potential to impact the NRCs ability to perform
its regulatory function, the NRC team evaluated the performance deficiency using traditional
enforcement. The violation was evaluated using Section 2.3.11 of the NRC Enforcement
Policy, because the failure to submit a required licensee event report may impact the ability
of the NRC to perform its regulatory oversight function. In accordance with Section 6.9.d,
Example 9, of the NRC Enforcement Policy, this violation was determined to be a Severity
Level IV non-cited violation. Because this violation involves the traditional enforcement
process and does not have an underlying technical violation, the NRC team did not assign a
cross-cutting aspect to this violation, in accordance with IMC 0612, Appendix B. (Section
6.7.4.2)
Licensee-Identified Violations
Violations of very low safety significance that were identified by Entergy have been reviewed by
the NRC. Corrective actions taken or planned by Entergy have been entered into the stations
corrective action program. These violations and corrective action tracking numbers are listed in
Section 9 of this report.
Enclosure
21
REPORT DETAILS
1. Performance History
PNPS transitioned into the Repetitive Degraded Cornerstone Column (Column 4) of the Reactor
Oversight Process Action Matrix as of the first quarter of 2015. This resulted from issuance of a
White finding under the Mitigating Systems cornerstone while PNPS was already in the
Degraded Cornerstone Column (Column 3) for more than five consecutive quarters due to two
open White inputs (unplanned scrams and unplanned scrams with complications) under the
Initiating Events cornerstone. In IP 95002 Supplemental Inspection Report 05000293/2014008
(ML15026A069), dated January 26, 2015, the NRC noted that PNPS did not adequately
evaluate the causes and take or plan timely corrective actions to address the issues associated
with a high number of unplanned scrams, some of which were complicated, which occurred in
2013. As a result, the two White inputs under the Initiating Events cornerstone remained open
for greater than five consecutive quarters, and were in effect when the new White finding was
identified during a special inspection team exit on March 20, 2015.
On January 27, 2015, PNPS experienced a partial LOOP during a winter storm. This resulted in
an automatic reactor scram that was complicated by several equipment problems. The NRC
dispatched a six-person special inspection team to the station on February 2, 2015, to review
Entergys organizational and operator response to the event, equipment response, and causes
of the event. On March 20, 2015, the special inspection team conducted an exit meeting with
Entergy management to discuss the results of the inspection, including a preliminary White
finding related to SRV performance. The results of this special inspection are documented in
NRC inspection report 05000293/2015007, issued on May 27, 2015 (ML15147A412).
On September 1, 2015, the NRC issued the final significance determination for the White finding
(ML15230A217). The White finding was associated with a violation of 10 CFR Part 50,
Appendix B, Criterion XVI, Corrective Action, in that Entergy did not identify, evaluate, and
correct a significant condition adverse to quality associated with the A SRV. Entergy did not
identify, evaluate, and correct the A SRVs failure to open upon manual actuation during a plant
cool-down on February 9, 2013, following a LOOP event caused by a winter storm. The failure
to take actions to preclude repetition resulted in the C SRV failing to open due to a similar
cause following a January 27, 2015, LOOP event also caused by a winter storm. The NRC
determined that the A SRV had been inoperable for a period greater than the technical
specification allowed outage time of 14 days.
The NRC closed the two White inputs under the Initiating Events cornerstone on June 30, 2015,
due to successful completion of the IP 95002 follow-up inspection (ML15169A946). The NRC
reviewed the White SRV finding as part of the IP 95003 Phase C inspection. The results of
that review are documented in Section 4 of this inspection report.
2. Licensee Site Recovery and Comprehensive Recovery Plan
In response to the stations transition to Column 4 of the Action Matrix, Entergy implemented a
diagnostic recovery process to determine what corrective actions would be needed to improve
performance at the station. This recovery process was similar to that implemented at another
Entergy site, Arkansas Nuclear One (ANO). Entergys recovery process consisted of four
phases: assessment phase, analysis phase, action plan development, and implementation
phase.
Enclosure
22
Assessment Phase
This phase resulted in development of assessment reports and problem descriptions to be

analyzed. Activities performed during the assessment phase included:
A comparative assessment review to determine whether weaknesses similar to the

fundamental problems and problem areas identified during the ANO NRC IP 95003
Recovery Process were also present at PNPS during the investigation period and may
have contributed to the stations performance decline.
A review of the stations identification, assessment, and resolution of performance

deficiencies, which included assessment of previous root cause evaluations and
associated corrective actions; the process for allocating resources with respect to safety
and compliance, backlog management, and the reduction of workarounds; and the
corrective action program.
A review of the adequacy of programs and processes associated with human

performance, procedure quality, and equipment performance.
Third-Party Nuclear Safety Culture Assessments conducted in 2015 and March 2016.
Entergy considered the results of the 2015 assessment for PNPS during the collective
evaluation process. The results of the 2016 assessment were analyzed for potential
additional problem descriptions.
Review of the root cause evaluation for the White finding related to the A SRV. This
root cause was undergoing further evaluation during the collective evaluation process.
The outcomes and corrective actions associated with the most recent revision to this
root cause evaluation are included in Entergys Comprehensive Recovery Plan.
Each assessment resulted in problems that were categorized as negative observations and/or
standards performance deficiencies. These assessment results were then binned into broader
standards performance deficiency rollups, and ultimately into problem descriptions.
Analysis Phase
The analysis phase involved two steps collective evaluation and cause analysis. The
collective evaluation analyzed the Assessment Phase results for patterns, trends, or groupings
to identify the major problem areas driving performance issues at PNPS. Once the major
problems were identified, an analysis was performed to determine the relationship between the
problems. The problems that caused other problems (i.e., drivers) were designated as
fundamental problems. Problems that were caused by the fundamental problems (i.e.,
driven) were designated as problem areas.
PNPSs Collective Evaluation Report documented three fundamental problems, and six problem
areas:
Enclosure
23
Fundamental Problems Problem Areas

Corrective Action Program Equipment Reliability
Nuclear Safety Culture Engineering Programs
Risk Mitigation and Decision-Making Procedure Quality
Procedure Use and Adherence
Work Management
Industrial Safety
The station performed root cause evaluations on all of the fundamental problems, as well as the
equipment reliability problem area. The remaining problem areas received apparent cause
evaluations. Though classified as a problem area, the station performed a root cause analysis
for equipment reliability since this area was a major factor in the issues that resulted in the
stations entry into Column 4. Based on the results of these cause evaluations, Entergy
developed corrective actions to preclude repetition and/or other actions to address each area.
During the collective evaluation process, two problem descriptions did not roll-up into any of the
fundamental problems or problem areas: operability determinations and functionality
assessments, and design engineering and licensing basis. Entergy conducted an apparent
cause evaluation on a problem description related to operability determinations and functionality
assessments. Issues related to the design and licensing basis problem description are captured
in the stations corrective action program under CR-PNP-2016-01476, CR-PNP-2016-01477,
CR-PNP-2016-02483, and CR-PNP-2016-02484.
Action Plan Development
Entergy reviewed all the corrective and improvement actions developed during their recovery
process, and then screened and organized the actions into the Comprehensive Recovery Plan.
The Comprehensive Recovery Plan is divided into six improvement areas, and their associated
area action plans, as described in the table below:
Improvement Area Area Action Plan

Corrective Action Program
SRV White Finding
Industrial Safety
Human Performance
Procedure Use and Adherence
Engineering Programs
Equipment Performance Equipment Reliability
Work Management
Leadership Risk and Decision-Making
Procedure Quality
Procedure Quality
Operability Determinations and Functionality Assessments
Nuclear Safety Culture, including the Independent Nuclear
Nuclear Safety Culture
Safety Culture Assessment Report Actions
Each area action plan included corrective actions, as well as effectiveness measures that
Entergy established to ensure that the Comprehensive Recovery Plan was achieving desired
outcomes in each area. Entergy was tracking and implementing Comprehensive Recovery Plan
actions through the stations corrective action program.
Enclosure
24
3. NRC Methodology and Diagnostic Assessment
3.1 Inspection Objectives
The intent of this inspection was to provide the NRC a comprehensive understanding of
the depth and breadth of safety, organizational, and performance issues at PNPS, and,
where data indicated, the potential for a more serious performance decline. The
objectives of this inspection were to:
Provide timely additional information to be used by the NRC in deciding whether

continued operation of the facility is acceptable and whether additional regulatory
actions are necessary to arrest declining plant performance.
Provide an independent assessment of risk significant issues to aid in the

determination of whether an unacceptable margin of safety exists.
Independently assess the adequacy of programs and processes used by Entergy to

identify, evaluate, and correct performance issues.
Independently evaluate and assess the adequacy of programs and processes in the
affected strategic performance areas.
Provide insight into the overall root and contributing causes of identified performance
deficiencies.
Evaluate Entergys third-party safety culture assessment and conduct a graded

assessment of PNPSs safety culture based on the results of the evaluation.
3.2 Inspection Scope
The NRC outlined the scope for this inspection in the 2015 PNPS mid-cycle assessment
letter, dated September 1, 2015 (ML15243A259). Based on the persistent corrective
action program weaknesses that resulted in PNPSs entry into the Repetitive Degraded
Cornerstone (Column 4), this IP 95003 supplemental inspection focused on PNPSs
corrective action program (IP 95003 Section 02.02) and safety culture assessment (IP
95003 Sections 02.07 02.09). Based on evaluation of inputs into the Action Matrix, the
reactor safety strategic performance area portion of the inspection focused on the key
attributes of human performance (IP 95003 Section 02.03c), procedure quality (IP 95003
Section 02.03d), and equipment performance (IP 95003 Section 02.03e).
Additionally, because the NRC had not completed the supplemental inspection for the
White finding related to the SRVs prior to the Phase C inspection, the scope of this
inspection included a review of that issue, using IP 95001, Supplemental Inspection
Response to Action Matrix Column 2 Inputs. The results of that review are documented
in Section 4 of this inspection report.
3.3 Inspection Approach
The NRC implemented a phased approach to complete the IP 95003 inspection

requirements at PNPS. The NRC chose a phased approach, in combination with
Enclosure
25
informed baseline inspection samples, to allow the Agency to monitor Entergys recovery
efforts, and to determine whether there was any further degradation in plant
performance that would require additional regulatory action to mitigate. A description of
NRC follow-up activities completed since PNPSs transition into Column 4 of the Action
Matrix are included in Section 4OA5 of each of the PNPS quarterly resident integrated
inspection reports3.
The NRC completed the Phase A portion of this supplemental inspection on

January 15, 2016. The purpose of this phase was to review aspects of PNPSs
corrective action program and to determine whether continued operation of PNPS was
acceptable and if additional regulatory actions were necessary to arrest declining plant
performance. The results of the Phase A inspection are documented in NRC
Inspection Report 05000293/2016008 (ML16060A018). The Phase B inspection
reviewed PNPSs overall corrective action program performance since the last biennial
problem identification and resolution inspection in August 2015. The results of the
Phase B inspection are documented in NRC Inspection Report 05000293/2016009
(ML16144A027). This inspection was the Phase C portion of the inspection, and
satisfied the remaining inspection requirements in IP 95003 for PNPS.
4. Review of White Safety/Relief Valve (SRV) Finding
4.1 Background
On January 27, 2015, PNPS was reducing reactor power, in accordance with station
procedures, due to loss of one of the two 345KV offsite distribution lines during a winter
storm. While at 52 percent power, operators observed a generator load reject and
automatic reactor scram when the remaining 345KV offsite distribution line
deenergized. Operator response to the scram was challenged by multiple equipment
issues, including failure of the C SRV to operate at low pressure. The NRC dispatched
a special inspection team to review the event.
The special inspection team identified a White violation of 10 CFR Part 50, Appendix B,
Criterion XVI, Corrective Action, in that Entergy did not identify, evaluate, and correct a
significant condition adverse to quality associated with the A SRV. Specifically, Entergy
did not identify, evaluate, and correct the A SRVs failure to open upon manual
actuation during a plant cooldown on February 9, 2013, following a LOOP event caused
by a winter storm. The failure to take actions to preclude repetition resulted in the C
SRV failing to open during the January 27, 2015, event described above. More
information on this event and the White violation can be found in NRC Inspection
Reports 05000293/2015007 and 05000293/2015011 (ML15147A412 and
ML15230A217, respectively).
4.2 NRC Inspection Scope
IP 95003 directs that the scope of the inspection shall include inspection of Entergys
root cause, extent of cause, and extent of condition evaluations and associated
corrective actions associated with the White SRV inspection finding if the associated
supplemental inspection procedure has not yet been completed. During the Phase C
3
ADAMS Accession Numbers: 2015003 (ML15317A030), 2015004 (ML16042A327), 2016001
(ML16133A433), 2016002 (ML16223A529), 2016003 (ML16319A206), 2016004 (ML17045A524)
Enclosure
26
inspection, the NRC team reviewed this issue in accordance with IP 95001,
Supplemental Inspection Response to Action Matrix Column 2 Inputs. The objectives
of this inspection were to:
Assure that the root causes and contributing causes of the significant
performance issues are understood
Independently assess and assure that the extent of condition and extent of cause
of significant performance issues are identified
Assure that corrective actions taken to address and preclude repetition of

significant performance issues are prompt and effective
Assure that corrective action plans direct prompt actions to effectively address
and preclude repetition of significant performance issues
The NRC team reviewed causal evaluations, procedures, and other documents which
supported Entergys evaluation of and actions to address the White finding, including:
CR-PNP-2013-00825: CR documenting SRV A performance information from

the February 2013 event
CR-PNP-2015-00561: Equipment apparent cause evaluation associated with the

failure of SRV C to fully open during manual operation
CR-PNP-2015-01520: CR associated with testing and disassembly of SRV A
CR-PNP-2015-01983: Apparent cause evaluation associated with failure of SRV

A to fully open at low pressure
CR-PNP-2015-05533: Root cause evaluation associated with the failure to

identify, evaluate, and correct the A SRV failure to fully open during manual
operation at low pressure
CR-PNP-2015-05827: Root cause evaluation associated with the failure of SRV

C to fully open during manual operation
CR-PNP-2016-01621: Root cause evaluation associated with the failure to

classify the A SRV as inoperable
The NRC team reviewed corrective actions, both completed and planned, to address the
identified causes, extent of condition, and extent of cause. The NRC team interviewed
Entergy personnel to ensure that the root and contributing causes and the contribution of
safety culture components were understood, and corrective actions taken or planned
were appropriate to address the causes and preclude repetition. These interviews
included the reactor operators and senior reactor operators involved in the 2013 and
2015 events where the A and C SRVs did not operate as required. The NRC team
also conducted in-plant walkdowns, including independent inspections of the control
room and simulator control room.
Enclosure
27
At the time of the inspection, root cause evaluation CR-PNP-2016-01621, Revision 2,

was the most recent evaluation addressing Entergys failure to identify, evaluate, and
correct the A SRVs failure to open upon manual actuation during a plant cooldown on
February 9, 2013. Unless otherwise noted, this is the revision discussed in this section.
4.3 Problem Identification (IP 95001, Section 02.01)
a. IP 95001, Section 02.01a, requires that the inspection staff determine that Entergys
evaluation of the issue documents who identified the issue (i.e., licensee-identified, self-
revealing, or NRC-identified) and under what conditions the issue was identified.
The following was excerpted from root cause evaluation CR-PNP-2016-01621:
This was a self-revealing event. In 2015, Winter Storm JUNO led to a

load reject and reactor scram. In support of the plant shutdown and cool
down, safety relief valve C failed to open with manual actuation at low
reactor pressure. A later 2015 inspection of the C valve revealed fretting
in the main piston guide causing friction on the main valve piston. The
extent of condition review concluded that safety relief valve A did not
open on demand during the 2013 NEMO storm and it was concluded that
the valve was inoperable since that time.
The NRC team determined that Entergys root cause evaluation adequately documented
that this was a self-revealing issue, and outlined the conditions under which the issue
was identified.
b. IP 95001, Section 02.01b, requires that the inspection staff determine that Entergys
evaluation of the issue documents how long the issue existed and prior opportunities for
identification.
Entergys root cause evaluation CR-PNP-2016-01621 stated, On March 12, 2015, as

the result of an extent of condition from SRV C failure to open, it was identified that
SRV A had also failed to open on February 9, 2013, going undetected for 25 months.
The root cause evaluation also documented prior opportunities for the station to identify
the issue, including:
On February 9, 2013, the issue with SRV A was not logged, a CR was not
initially documented, and additional operations expectations for shift turnover,
communication, and control room presence were not met.
On February 11, 2013, a work request was prepared that included the incorrect
conclusion, Tail pipe temperature indicated valve was open, which resulted in
the creation of a work order to resolve SRV A acoustic monitor issues, rather
than a work order to evaluate SRV A performance.
On February 11, 2013, the senior reactor operator that prepared the immediate
operability determination for CR-PNP-2013-00825 did not adequately utilize
steam tables to verify that SRV A did not open on demand.
Enclosure
28
On February 11, 2013, the shift manager did not perform a rigorous review of the
immediate operability determination for CR-PNP-2013-00825 prior to approval.
On February 13, 2013, the Condition Review Group did not create an additional
action to evaluate performance of SRV A.
On February 13, 2013, the responsible manager assigned to CR-PNP-2013-

00825 did not create an additional action to evaluate performance of SRV A.
On February 13, 2013, the engineer assigned to CR-PNP-2013-00825 did not

determine and document whether the acoustic monitor had worked prior to
closing the corrective action concluding the issue was resolved.
On February 13, 2013, the post-trip review team did not identify that SRV A
failed to open, and additional subsequent post-trip review package reviews did
not identify the SRV A deficiency.
Overall, the NRC team determined that Entergys root cause evaluation adequately
documented how long the issue existed and the multiple missed opportunities to identify
that the A SRV had not opened on February 9, 2013.
c. IP 95001, Section 02.01c, requires that the inspection staff determine that Entergys
evaluation documented significant plant-specific consequences, as applicable, and
compliance concerns associated with the issue(s).
The following is excerpted from root cause evaluation CR-PNP-2016-01621:
The actual consequences as stated in the problem statement were SRV

A was inoperable for an extended period of time and a similar failure of
SRV C in January 2015 was not prevented. There were no actual
consequences to general safety of the public, nuclear safety, industrial
safety and radiological safety of this event Based on the risk analysis
by the NRC and Entergy the risk was identified as moderate (White) as
documented in the final significance determination.
The root cause evaluation also summarized causal factors and compliance concerns
associated with the issues. These causal factors included: (1) non-compliance with
procedures; (2) insufficient knowledge and skill; (3) inadequate oversight by the
operability determination approver and post-trip review approvers; (4) inadequate
information path; (5) lack of individual rigor; (6) lack of individual accountability; (7) lack
of managerial accountability; (8) inadequate maintenance practices; and (9) lack of
operations and control room oversight.
Overall, the NRC team determined that Entergys evaluation adequately documented
significant plant-specific consequences, as applicable, and compliance concerns
associated with the issues.
Enclosure
29
4.4 Root Cause, Extent of Condition, and Extent of Cause Evaluation (IP 95001, Section
02.02)
a. IP 95001, Section 02.02a, requires that the inspection staff determine that the problem
was evaluated using a systematic methodology to identify the root and contributing
causes.
The NRC team noted that Entergys evaluation of this issue required multiple cause
evaluations. Root cause evaluation CR-PNP-2015-05533, Revision 1, completed on
November 12, 2015, initially determined that the root cause was a lack of leadership
intrusiveness, due to valuing results over behaviors, which led to the PNPS engineering,
maintenance, and operations departments failing to use systematic processes to
evaluate the anomalous operation of the A SRV. Because significant flaws were found
in this root cause evaluation during the recovery process, Entergy initiated CR-PNP-
2016-01621 on March 4, 2016, and conducted another root cause evaluation of the
issue.
Entergy used the following systematic methods to determine the causes and corrective
actions for root cause evaluation CR-PNP-2016-01621: Event & Causal Factor
Charting, Barrier Analysis, Why Staircase, Comparative Timeline, Organizational &
Programmatic Evaluation, and Management Oversight and Risk Tree analysis. Entergy
also performed document reviews, interviews, observations, internal reviews, and
external reviews. Entergy identified the direct cause, two root causes, and three
contributing causes in CR-PNP-2016-01621:
Direct Cause: Maintenance, engineering, operations, and Condition Review

Group personnel focused evaluation and correction activities on the acoustic
monitor for SRV A instead of the valve because information in CR-PNP-2013-
00825 was incomplete.
Root Cause 1: Operations managers did not provide effective reinforcement to

the operations department of the standards and expectations for the conduct of
operations that apply during plant transient conditions.
Root Cause 2: PNPS personnel practiced insufficient accountability and rigor

during performance of the Post-Trip Review Preliminary Safety Assessment for
the station scram in February 2013.
Contributing Cause 1: Licensed operator fundamental training was ineffective in

providing the necessary knowledge to properly interpret steam tables.
Contributing Cause 2: PNPS management oversight failed to ensure corrective

action and operability determination processes were implemented as required.
Contributing Cause 3: Instrumentation & Control maintenance personnel failed

to conduct work on SRV A acoustic monitor in accordance with the approved
work document.
The NRC team determined that Entergy generally used a systematic methodology to
identify the root and contributing causes. However, during this review, the NRC team
Enclosure
30
determined that root cause evaluation CR-PNP-2016-01621 did not have stand-alone
quality, as specified in Entergy procedure EN-LI-118-PNP-RC, 95003 Root Cause
Evaluation Process, Section 5.2, which stated that cause evaluation reports will have
stand-alone quality by presenting facts and other data to clearly support the causes
determined and that specified corrective actions will address the causes. Specifically,
root cause evaluation CR-PNP-2016-01621 did not include a review of the mechanical
failure mechanism of SRV A. Entergy noted that an apparent cause evaluation on the
mechanical aspects of the SRV A issues, CR-PNP-2015-01983, and a root cause
evaluation on the mechanical aspects of the SRV A issues, CR-PNP-2015-05827, had
already been performed to adequately resolve these aspects of SRV performance. The
NRC team reviewed these cause evaluations and determined that neither of the cause
evaluations, nor any other cause evaluation, was specifically completed at the root
cause level to address the hardware issues associated with SRV A. Rather, Entergy
discussed the mechanical aspects of the SRV A failure in an extent of condition review
in CR-PNP-2015-05827. CR-PNP-2015-05827 stated that both SRV A and SRV C
exhibited rolled threads (indicative of an excessive impact force being applied) and
shortened main stage spring lengths. Though not performing a root cause evaluation on
the SRV A hardware aspects could represent a missed opportunity to identify other
issues with SRV performance, the NRC team determined that this would likely have had
minimal impact on the results of root cause evaluation CR-PNP-2016-01621, which
focused on why the station failed to identify that the A SRV did not open in 2013.
Additionally, all of these three-stage SRVs were removed and replaced with two-stage
valves in May 2015 that are not considered susceptible to the failure mechanism
associated with the A and C SRV failures in 2013 and 2015. Entergy documented this
issue in CR-PNP-2017-00828.
b. IP 95001, Section 02.02b, requires that the inspection staff determine that the root cause
evaluation was conducted to a level of detail commensurate with the significance of the
problem.
The NRC team noted multiple issues in root cause evaluation CR-PNP-2016-01621.
The following examples associated with the root cause methodologies utilized by
Entergy illustrate incorrect conclusions, incorrect assumptions, inadequate rationale for
ruling out alternative possible root causes, and the extent to which the incorrect
conclusions and assumptions impacted the root cause evaluation, and its overall
conclusions:
Why Staircase Methodology
In root cause evaluation CR-PNP-2016-01621, Entergys Staircase 2: Operability

Determination Process analysis began with the question: Why did the operability
determination performed by control room supervisor #2 (and approved by shift manager
#2) conclude that SRV A opened? Entergys response to this Why Staircase
question included, Because the licensed operators believed SRV A opened based on
tailpipe temperature rise from 130 to 220 and believed the acoustic monitor did not
function properly.
This conclusion was not consistent with the stations interviews nor the NRC teams
interviews. Specifically, Entergys interview records (documented in CR-PNP-2016-
01621) indicated that the reactor operator involved in the event knew that SRV-3A did
Enclosure
31
not open. Additionally, the interview records indicate that the control room supervisor
suspected that there was an issue with SRV-3A and had notified the shift manager.
The control room supervisor indicated to the NRC team that a CR had not been initially
written on February 9, 2013, following the event. Subsequently, the control room
supervisor submitted CR-PNP-2013-00825 on February 11, 2013. The following was
excerpted from the condition description of CR-PNP-2013-00825:
During plant cooldown, when reactor pressure was about 100 psig, SRV
A did not register on the acoustic monitor when its switch was taken to
OPEN. Cooldown was accomplished using HPCI in pressure control.
Tailpipe temperature did show an increase to about 220 [degrees] F.
The immediate action description of the CR stated, SRV C & D were used since they
did show a change on the acoustic monitor, and the suggested action description of the
CR stated, Evaluate performance of the SRV A. Based on the information available in
CR-PNP-2013-00825 and the interview results discussed above, the NRC team did not
agree with Entergys conclusion that the licensed operators believed that A SRV had
opened based on the tailpipe temperature and that the acoustic monitor had functioned
improperly.
The NRC team also assessed whether Entergys root cause evaluation incorrectly ruled
out alternative possible root causes due to the error in Staircase 2: Operability
Determination Process. The following was excerpted from CR-PNP-2016-01621:
The why staircase determined that the cause of the incorrect Operability
Determination related to SRV A was due to Training organization
deficiencies in existence at the time and the operator performance
relative to Operability Determinations reflected these Training
weaknesses and resulted in a weakness in Operator [Fundamentals].
The NRC team determined that this conclusion was not supported by the stations
interviews or the NRC teams interviews. The immediate operability determination for
CR-PNP-2013-00825, performed by a different control room supervisor than was
involved in the February 9, 2013, event, stated, No Degraded or Nonconforming
Condition existsThe tailpipe thermocouple indicated the SRV was open based on
vessel saturation temperatures. SRV surveillance instrumentation for RV-203-3A are
operable. The NRC team reviewed Entergys interview records with the operations
personnel involved in the February 2013 event, and recognized that the control room
supervisor that drafted the immediate operability determination demonstrated training
weaknesses that resulted in a weakness in operator fundamentals. Specifically, the
control room supervisor used the steam tables for the operability determination and
incorrectly concluded that SRV A had opened.
However, the NRC team determined that the shift manager that approved the immediate
operability evaluation did not exhibit the same training weaknesses as the control room
supervisor. The shift manager indicated to the NRC team in interviews that he/she had
reviewed the operability determination, but had not specifically explored the statement,
The tailpipe thermocouple indicated the SRV was open based on vessel saturation
temperatures. The shift manager also indicated that there was extensivetraining on
the 3-stage safety relief valves. Both Entergys interviews and the NRC teams
Enclosure
32
interviews with the shift manager that approved the operability determination support the
NRC teams conclusion that the shift manager possessed adequate training and
knowledge to ensure an adequate operability determination was completed. The cause
of the incorrect and inadequate operability determination related to SRV A was
associated with inadequate shift manager review rigor and any causal factors that
impact the shift managers ability to complete rigorous reviews of operability
determinations.
Barrier Analysis Methodology
The barrier analysis for root cause evaluation CR-PNP-2016-01621 attempted to identify
causal factors that allowed the events to occur because barriers were ineffective, weak,
or missing. The causal factors were then combined into contributing and root causes or
used as supporting examples. Entergy identified the following as ineffective barriers, as
excerpted from CR-PNP-2016-01621:
Operator Fundamentals (Log Keeping)

Operability Determination Process
Corrective Action Program (CR Initiation Level of Detail)
Corrective Action Program (Timeliness of CR Initiation)
Post-Trip Review
Conduct of Operations (Control Room and Operations and Operations
Administrative Policies and Processes)
Maintenance Fundamentals
Entergy concluded that the operability determination process barrier was ineffective
because of a knowledge gap. However, though a portion of the barrier analysis stated
that the shift manager trusted the control room supervisors operability evaluation,
Entergy did not cite shift manager operability determination review rigor as one of the
reasons for the ineffective operability determination process barrier. As previously
described, the NRC team concluded that the shift manager possessed adequate training
and knowledge to ensure an adequate operability determination was completed, and
inadequate shift manager review rigor (and any associated causal factors) contributed to
this barrier being ineffective.
Entergy stated that the corrective action program barrier was ineffective because the
details in CR-PNP-2013-00825 were inadequate to clearly define the condition. The
following information was excerpted from Entergy CR-PNP-2013-00825:
During plant cooldown, when reactor pressure was about 100 psig, SRV
A did not register on the acoustic monitor when its switch was taken to
OPEN. Cooldown was accomplished using HPCI in pressure control.
Tailpipe temperature did show an increase to about 220 [degrees] F.
The NRC team agreed that the timeliness for issuing CR-PNP-2013-00825 did not meet
Entergys corrective action program expectations. The NRC team also agreed that
additional information could have been included when CR-PNP-2013-00825 was written.
However, given the values included for reactor pressure and tailpipe temperature, a
knowledgeable senior reactor operator, like the shift manager, would be expected to
effectively utilize steam tables or sufficiently challenge an inadequate operability
Enclosure
33
determination and determine that the tailpipe thermocouple indicated SRV A had not
opened based on vessel saturation temperatures. Additionally, the Suggested Action
Description section of CR-PNP-2013-00825 stated, Evaluate performance of SRV A.
Hence, the NRC team concluded that though the timeliness of CR-PNP-2013-00825 did
not meet corrective action program expectations, the details that were provided were
adequate to initiate an appropriately rigorous operability determination review to identify
the condition. As a result, the NRC team disagreed with Entergys conclusion that the
barrier associated with the CR-PNP-2013-00825 Barrier Analysis Worksheet 3
Corrective Action Process was ineffective.
With respect to the maintenance fundamentals and work management barrier, Entergy
stated:
The barrier worked as designed. The [work request] was written based
on the condition report that was written on the condition of the acoustic
monitor not functioning. The CR contained wording that indicated that the
SRV A valve had opened and this was transferred to the [work request]
which resulted in the [work request/work order] being written only to
address the acoustic monitor.
Based on review of the information in CR-PNP-2013-00825, the NRC team determined

that there was no wording in the CR that indicated SRV A had opened. The NRC team
therefore concluded that the work request was written based on an interpretation or
incorrect assumption associated with CR-PNP-2013-00825, versus being written on the
actual condition and indications described in the CR. Hence, the NRC team disagreed
that the work management and planning process barrier worked as designed, and that
the work request was written based on the CR description.
Comparative Timeline Methodology
The NRC team reviewed details of the comparative timeline worksheets, and noted that
Entergys conclusion that CR-PNP-2013-00825 was inadequate adversely impacted how
the causes of this event were determined. The following was excerpted from this portion
of Entergys analysis:
How maintenance, engineering, operations and corrective action

personnel reacted to the description in the CR is the direct cause (trigger)
for this event. Maintenance, engineering, operations and [Condition
Review Group] personnel decided to focus on the acoustic monitor, not
the SRV A failure to open on demand. The incomplete [CR] description
is not causal because it included enough information to identify the SRV
deficiency.
The NRC team agreed with the first sentence of this quotation and agreed that the CR
description is not causal. However, this statement does not support the direct cause of
the event, as listed in Section 4.4a. The NRC team could not reconcile how Entergy
concluded that the CR description was not causal, but determined the direct cause was
because information in CR-PNP-2013-00825 was incomplete.
This portion of Entergys analysis also stated, The suggested action was to evaluate
performance of the SRV A. That was not done. If the post-CR generation barriers
Enclosure
34
were effective, then the SRV deficiency would have been identified. This statement
supported the NRC teams conclusions that the post-CR generation barriers, like the
operability determination process, which included an inadequate shift manager review of
CR-PNP-2013-00825, should have identified the SRV deficiency. Therefore, ineffective
barriers prior to the initiation of CR-PNP-2013-00825 appear to have contributed to the
event, and ineffective barriers post-initiation of CR-PNP-2013-00825 appear to be more
significant causal factors.
The NRC team also reviewed work request 298475 for the SRV A acoustic monitor not
working during cooldown. The work request included information stating SRV A was
open based on tail pipe temperature. The following was excerpted from Entergys
comparative timeline worksheet:
The inclusion of the incorrect information related to SRV A opening in

the additional information in the [work request] based on tail pipe
temperature is not significant to the event to more clearly identify and
document the condition with the SRV A valve. The condition report CR-
PNP 201[3]-00825 was written and included information stating that the
valve had opened based on tailpipe temperature readings. Using the
available CR information when generating a [work request] to make
repairs is an expected behavior. If the work management or planning
department would have further investigated or questioned the issue, it is
very likely that the [work request] originator would have verified the
additional information related to SRV A opening. This would have
resulted in the planning efforts to be focused on the acoustic monitor only.
It is possible that questions could have been asked concerning the
operation of the valve and the recommended actions to evaluate the
valve could have been more pursued with the operator. This could have
resulted in an opportunity to further clearly identify and document the
issue with the SRV A valve.
The NRC team disagreed with these conclusions and assumptions. Specifically, CR-
PNP-2013-00825 did not include information stating that the valve had opened based on
tailpipe temperature readings. If the work management or planning department would
have further investigated or questioned the issue, the work request originator would
have verified that SRV A did not open. Hence, the planning efforts would not be
expected to be focused on the acoustic monitor only. The NRC team determined that
the work request being written to troubleshoot the acoustic monitor for SRV A, as
opposed to evaluating the performance of the valve, appears to be a more significant
causal factor.
Management Oversight Risk Tree (MORT)
The NRC team noted that the same conclusions and assumptions regarding the
adequacy of CR-PNP-2013-00825 impacted the MORT analysis as well. The following
was excerpted from the Management System Factors Implementation section of
Entergys MORT analysis:
The CR generated two days later did not contain sufficient information for
subsequent reviews to determine that the valve did not open. Procedure
EN-LI-201, Corrective Action Process, step 5.2.2.e, at the time of the
Enclosure
35
event stated the condition description and any supporting documentation

should be in sufficient detail to provide a clear understanding of the
condition. Contrary to this requirement, the CR description did not
provide a clear understanding of the condition.
This contradicted another section of the MORT analysis (a4) which stated, The CR did
contain reactor pressure and tailpipe temperature information that, if reviewed with a
conservative bias, would have led reviewers to conclude that the valve may not have
opened.
As previously established, although the NRC team agreed that additional information
could have been included when CR-PNP-2013-00825 was written, the NRC team
determined that the reactor pressure and tailpipe temperature information available in
CR-PNP-2013-00825 was sufficient for a knowledgeable senior reactor operator to
effectively utilize steam tables and determine that SRV A had not opened based on
vessel saturation temperatures. Thus, the NRC team disagreed with Entergys MORT
analysis conclusion which stated, Incomplete information in CR-PNP-2013-00825 led
plant personnel and processes to focus on the acoustic monitor for SRV A instead of
the valve itself, and this is the Direct Cause of the event.
Entergy procedure EN-LI-118-PNP-RC, 95003 Root Cause Evaluation Process,

defined the direct cause as, The immediate human action or equipment failure
mechanism that triggered an event or condition. This is not the apparent or root cause
of the event. The NRC team determined that the direct cause did not appear to be fully
comprehensive, and that the equipment failure mechanism associated with the A SRV
triggered the chain of events that resulted in the failure to identify, evaluate, and correct
the significant condition adverse to quality associated with the A SRV.
Based on review of the MORT analysis, the NRC team was unable to follow the rationale
for ruling out the inadequate shift manager review as a possible root cause. The
following was excerpted from the Task Performance Errors section of Entergys MORT
analysis:
The Shift Manager that approved the operability determination performed

on SRV A did so without giving it an adequate reviewAlthough the
Shift Manager did provide his approval of the operability determination by
signing it at the end of his shift, he stated in interviews that he did not
review the operability determination in any detailThe Shift Manager did
not demonstrate sufficient accountability to review the operability
determination adequately, and this was a missed opportunity to determine
the operability determination was flawed.
This was further supported by the Management System Factors Implementation

section, which indicated that the lack of management oversight associated with the
operability determination contributed to the incorrect operability conclusion. It stated:
The operability description included that The tailpipe thermocouple

indicated the SRV was open based on vessel saturation temperatures.
This conclusion was incorrect based on the reactor pressure and the
Enclosure
36
tailpipe temperature stated in the CR. Contributing to this was a lack of

management oversight, which is discussed in the Services Branch of the
MORT.
The NRC team reviewed the Services section of Entergys MORT analysis related to
the lack of management oversight. The following was excerpted from this section:
The Shift Manager is responsible to review and approve operability

determinations dispositioned on their shift. This review and approval was
inadequate, as the fundamental flaws in the operability determination
were not discovered. The review and approval lacked the intrusive
management oversight required to ensure standards of the operability
determination process were being maintainedInadequate oversight was
determined to be causal to this event, and the following Root cause is a
result: Contributing Cause 2: PNPS Management oversight failed to
ensure corrective action and operability determination processes were
implemented as required.
The NRC team agreed that the shift manager is ultimately responsible for the
conclusions of operability determinations dispositioned on his or her shift. CR-PNP-
2013-00825 was placed in the corrective action program and contained sufficient
information for the operability determination to conclude that SRV A did not open.
Though the flawed draft of the operability determination appears to have contributed to
the shift managers inadequate performance of his or her ultimate responsibility of
ensuring correct operability determinations in transient and non-transient situations, the
rigorous operability review was the responsibility of the shift manager.
Entergy identified failure of PNPS management oversight of the corrective action and
operability determination processes as Contributing Cause 2. However, the NRC team
determined that Entergy did not adequately focus on the shift managers role as part of
that oversight despite the fact that multiple cause evaluation methodologies, including
the MORT analysis, identify this as an issue. As a result, the NRC team concluded that
Entergy inappropriately assessed the impact of shift manager review rigor and any
associated causal factors in root cause evaluation CR-PNP-2016-01621. This was
further illustrated by the corrective actions developed to address this cause, which
broadly address station management and ongoing operability determination issues, and
do not specifically address shift manager rigor concerns.
Finally, the NRC team determined that Root Cause 1 narrowly focused on operations
management actions during plant transients, even though the inadequate operability
determination and inadequate review were completed two days after the plant transient
condition during which SRV A failed to operate.
Overall Summary
The NRC team identified the collective issues associated with the root cause
methodologies as a significant weakness, such that the objectives of IP 95001 could not
be satisfied. Most notably, the incorrect conclusions and assumptions related to the
adequacy of information in CR-PNP-2013-00825 adversely impacted four of the cause
evaluation methodologies used in root cause evaluation CR-PNP-2016-01621.
Specifically, though documentation in CR-PNP-2013-00825 could have been enhanced,
Enclosure
37
the details that were provided were adequate for an appropriately rigorous operability
determination review to identify that SRV A did not open. This ultimately resulted in
Entergy inappropriately assessing the impact of shift manager review rigor, and any
associated causal factors, in root cause evaluation CR-PNP-2016-01261. This
inappropriate assessment, coupled with other incorrect conclusions and assumptions in
the Why Staircase, Barrier Analysis, Comparative Timeline, and MORT analyses of root
cause evaluation CR-PNP-2016-01261 impacted the adequacy of the overall
conclusions documented in Entergys root cause evaluation. Entergy documented this
issue, and the specific issues discussed in this section, in CR-PNP-2017-00363 and CR-
PNP-2017-00828. The NRC team documented a finding associated with this issue in
Section 4.7 of this report.
c. IP 95001, Section 02.02c, requires that the inspection staff determine that the root cause
evaluation included a consideration of prior occurrences of the problem and knowledge
of prior operating experience.
The CR-PNP-2016-01621 root cause evaluation documented a review of internal and

external operating experience. The operating experience review ultimately identified 12
internal and 23 external operating experiences with applicable lessons regarding
inadequate evaluation and correction of issues which in some cases led to repeat
issues. Additionally, CR-PNP-2016-01621 documented relevant events from
February 8, 2013, through March 25, 2013.
The NRC team noted that the operating experience reviews in CR-PNP-2016-01621 did
not appear to consider potentially relevant operating experience that was documented in
root cause evaluation CR-PNP-2015-05827, which evaluated the event, SRV-3C Did
Not Fully Open during Manual Operation. Among the operating experience that was not
considered were CR-PNP-2013-00011, CR-PNP-2013-05651, a General Electric
Services Information Letter, and an NRC Information Notice.
CR-PNP-2013-00011, initiated on January 2, 2013, discusses a new SRV that failed

initial steam testing at a vendor facility. The valve was disassembled and small albrite
scratches and unacceptable blemishes were found on the internal body of the valve.
CR-PNP-2013-05651, initiated on August 6, 2013, discussed off-site testing of a Target
Rock 3-stage SRV that resulted in the main stage failing to reclose fully after the first lift
on the test stand. The valve was disassembled and internal damage was identified to
the main disc stem threads, main guide, main piston threads, and main piston rings.
CR-PNP-2013-05651 also noted that similar damage to a Target Rock main stage has
been reported in General Electric Services Information Letter No. 646, Target Rock
Safety Relief Valve Failure to Fully Open, dated December 20, 2002, and NRC
Information Notice 2003-01, Failure of a Boiling Water Reactor Target Rock Main
Steam Safety/Relief Valve, dated January 15, 2003.
The NRC team noted that the absence of this operating experience appears to be
contrary to Entergy procedure EN-LI-118-PNP-RC, 95003 Root Cause Evaluation
Process. The NRC team determined this issue was minor, as failure to consider this
operating experience would not have affected the conclusions of the cause evaluation.
Entergy documented this issue in CR-PNP-2017-00828 in response to the NRC teams
questions.
Enclosure
38
d. IP 95001, Section 02.02d, requires that the inspection staff determine that the root cause
evaluation addressed the extent of condition and the extent of cause of the problem.
Extent of Condition
Root cause evaluation CR-PNP-2016-01621 defined the extent of condition as the

extent to which other instances of failure to identify, evaluate, and correct for a same or
similar significant condition adverse to quality had occurred and resulted in or could
result in a repeat event. The NRC team noted that Entergy limited their extent of
condition review to PNPS. Entergys basis for this bounding condition was: Although
other stationsin the Entergy fleet have SRVs/[power operated relief valves], they are
excluded from the extent review because other stations do not operate at [PNPS].
Thus, the evaluation did not include Entergy personnel at other stations or the corporate
offices and consider if these personnel failed to identify, evaluate, and correct a
significant condition adverse to quality associated with an SRV. During review of ANO
NRC Supplemental Inspection Report 05000313/2016007 and 05000368/2016007
(ML16161B279), the NRC team noted that Entergy identified that a significant
contributor to the performance problems at the station was ineffective implementation
and oversight of the corrective action program. Similarly, NRC Yellow findings
associated with a stator drop and flooding event at ANO identified problems with
corrective action program implementation and quality, in that staff at ANO did not identify
a significant condition adverse to quality. As such, the NRC team disagreed with
Entergys bases for bounding their extent of condition review to PNPS. Considering
recent fleet operating experience, the NRC team did not view the work place location as
a bases for assuming that Entergy personnel at other stations had not failed to identify,
evaluate, and correct a significant condition adverse to quality associated with an SRV,
or some other significant condition adverse to quality.
Additionally, for the review, Entergy expanded the condition beyond just SRVs to failure
to identify, evaluate, and correct a significant condition adverse to quality associated with
other safety-related equipment, including important to safety equipment, and
Maintenance Rule (high critical equipment), and plant programs/processes (Corrective
Action Program, Security, Emergency Preparedness, Training, Human Performance,
Industrial Safety, Operability Determinations, Operator Rounds, Work Management,
Equipment Reliability, Maintenance Program, and Fire Protection). The extent of
condition review noted that the corrective action program root cause evaluation (CR-
PNP-2016-00716) adequately bounded and evaluated the corrective action program
extent of condition; CR-PNP-2015-05827 adequately resolved mechanical operation
aspects of the SRVs; and failures to identify, evaluate, and correct significant conditions
adverse to quality associated with other important to safety plant programs and
processes, were known to exist.
The NRC team observed that Entergy did not document an extent of condition review
related to the mechanical aspects of the A SRV issue. However, the NRC team noted
that the CR-PNP-2016-01621 root cause evaluation stated that all four SRVs were
replaced with different style valves in spring 2015. CR-PNP-2015-05827 documented
that SRV-3A and SRV-3C were replaced during a forced outage under work orders
52372900 and 00403856 on February 2, 2015, and during Refueling Outage 20, on
May 15, 2015, temporary modification engineering change (EC) 44839 was implemented
to replace all model 0867F 3-stage SRVs with model 7567F 2-stage valves.
Enclosure
39
In summary, the NRC team determined that there were weaknesses in Entergys extent
of condition review. Specifically, Entergy narrowly focused the extent of condition review
only on PNPS personnel, and did not document an extent of condition review associated
with the condition of the A SRV. Entergy documented CR-PNP-2017-00828 in
response to the NRC teams questions.
Extent of Cause
Root cause evaluation CR-PNP-2016-01621 evaluated the extent of cause for each of
the identified root and contributing causes. This extent of cause review identified a
number of additional extent of cause related corrective actions, and assessed the
applicability of the root causes across disciplines and departments for different
programmatic activities, human performance, and different types of equipment.
The NRC team determined that Entergy followed the EN-LI-118-PNP-RC process
requirements for extent of cause evaluations. The bounding conditions for the analyses
were appropriate, and the results of the extent of cause evaluation sufficiently
considered other programs and processes at PNPS. As such, the NRC team
determined that root cause evaluation CR-PNP-2016-01621 adequately addressed the
extent of the identified causes of the problem. However, more evaluation may be
needed once Entergy assesses the impacts of inadequate shift manager review rigor,
and any associated causal factors, on root cause evaluation CR-PNP-2016-01621.
e. IP 95001, Section 02.02e, requires that the inspection staff determine that the root
cause, extent of condition, and extent of cause evaluations appropriately considered the
safety culture traits in NUREG-2165, Safety Culture Common Language, referenced in
IMC 0310, Aspects Within Cross-Cutting Areas.
Revision 2 of root cause evaluation CR-PNP-2016-01621 discussed a safety culture

review that was performed to determine if safety culture aspects were a root or
contributing cause of the SRV White finding. Specifically, the Safety Culture section of
Entergys root cause evaluation identified 12 aspects that were determined to be weak
and related to the root and contributing causes. Entergys review stated, The nuclear
safety culture assessment identified weaknesses which were significant contributors to
the identified direct cause, two root causes, and three contributing causes. The aspects
that were identified as contributing to the root causes included: H.2, Field Presence; H.4,
Teamwork; H.11, Challenge the Unknown; H.14, Conservative Bias; X.5, Leader
Behaviors; and X.6, Standards. The additional aspects that were identified as
contributing to the contributing and direct causes included: H.5, Work Management; H.8,
Procedure Adherence; H.9, Training; P.1, Identification; P.2, Evaluation; and P.3,
Resolution. Entergy determined that the identified aspects were being addressed by the
corrective actions for all of the root and contributing causes.
The NRC team noted that H.10, Bases for Decisions, was not identified as an applicable
aspect for Contributing Cause 2, associated with PNPSs management oversight failure
to ensure corrective action and operability determination processes were implemented
as required. NRC IMC 0310 describes H.10 as, Bases for Decisions: Leaders ensure
that the bases for operational and organizational decisions are communicated in a timely
manner. NUREG-2165, Safety Culture Common Language, further describes this
aspect: Leaders encourage individuals to ask questions if they do not understand the
basis for operational and management decisions. The NRC team noted that the shift
Enclosure
40
manager that approved the operability determination associated with CR-PNP-2013-

00825 did not adequately ask questions to understand the basis of an operational
decision the declaration of SRV A as operable.
The NRC team also noted that H.13, Consistent Process, was also not identified as an
applicable aspect for Contributing Cause 2. NRC IMC 0310 describes H.13 as,
Consistent Process: Individuals use a consistent systematic approach to make
decisions. Risk insights are incorporated as appropriate. NUREG-2165 further
describes this aspect: Leaders take a conservative approach to decision making,
particularly when information is incomplete or conditions are unusual and Individuals
do not rationalize assumptions for the sake of completing a task. The NRC team noted
that the shift manager that approved the operability determination associated with CR-
PNP-2013-00825 did not take a conservative approach to decision-making when
information was incomplete or conditions were unusual, and rationalized assumptions
(i.e., that the operability determination that was provided for approval was sufficiently
rigorous), for the sake of completing a task.
The NRC team determined that there were weaknesses in the CR-PNP-2016-01621 root
cause, extent of condition, and extent of cause evaluations consideration of the safety
culture traits in NUREG-2165, because the NRC team noted at least two aspects that
did not appear to be properly considered to determine whether weaknesses in these
safety culture components was a root cause or significant contributing cause of the
performance issue. Entergy documented CR-PNP-2017-00828 in response to the NRC
teams questions.
f. IP 95001, Section 02.02f, requires that the inspection staff examine the common cause
analyses for potential programmatic weaknesses in performance when a licensee has a
second White input in the same cornerstone.
The NRC team was not required to examine a common cause analyses for potential
programmatic weaknesses in performance because the SRV White finding is the only
White input in the Mitigating Systems cornerstone.
4.5 Corrective Actions Taken and Planned (IP 95001, Sections 02.03 and 02.04)
a. IP 95001, Sections 02.03a and 02.04a, require that the inspection staff determine that
appropriate corrective actions are taken and/or planned for each root and contributing
cause or that Entergy has an adequate evaluation for why no corrective actions are
necessary. Section 02.04a also requires that the inspection staff determine that
corrective action plans have been prioritized with consideration of significance and
regulatory compliance.
The NRC team reviewed root cause evaluations CR-PNP-2015-05827 and CR-PNP-
2016-01621 to assess corrective actions taken to address the causes. The following
discussion is not meant to be exhaustive, but it outlines all completed CAPRs and some
other notable actions taken.
CR-PNP-2015-05827 Root Cause Evaluation
Entergy determined the direct cause of SRV-3C not fully opening was, fretting wear
between the main stage piston rings and guide liner causing increased opening stroke
Enclosure
41
friction. To address this direct cause, SRV-3A and SRV-3C were replaced during a
forced outage under work orders 52372900 and 00403856 on February 2, 2015, and a
Standing Order was established to direct operators to continue to utilize SRVs exhibiting
higher-than-normal opening friction to improve the popping action of the main disc by
burnishing off observed ridges on the piston rings in the main stage.
Entergy determined the root cause of SRV-3C not fully opening was, A Target Rock
valve design defect which causes excessive opening velocity; resulting in a high impact
load to the main disc stem and piston when the valve is actuated on the limited steam
flow test stand. To address this root cause, PNPS implemented temporary modification
EC 44839 during Refueling Outage 20, on May 15, 2015, to replace all model 0867F 3-
stage SRVs with model 7567F 2-stage valves. During Refueling Outage 21 in spring
2017, Entergy indicated that they intend to replace the control assembly in the four
existing 2-stage SRVs with new pilot assemblies with coated discs under work orders
00435308 (A SRV), 00435311 (B SRV), 00435314 (C SRV), and 00435316 (D
SRV).
CR-PNP-2016-01621 Root Cause Evaluation
This root cause evaluation stated that actions for Root Cause 1 and Root Cause 2 will
address the direct cause. To address Root Cause 1, Entergy implemented a CAPR
(CR-PNP-2016-01621 CA-11) to revise the licensed operator requalification long-range
training plan to include delivery of a case study and simulator-based exercise in
operations continuing training for the continual reinforcement of standards and
expectations for the conduct of operations during plant transient conditions this
material is to be presented on a 2-year frequency. The NRC team observed simulator
training and presentation of the case study that were part of the CAPR and determined
that the root cause discussed in the case study was not consistent with Root Cause 1 in
CR-PNP-2016-01621. Entergy noted the NRC teams concern immediately and entered
this corrective action weakness into the corrective action program as CR-PNP-2016-
09647. The NRC team determined that this issue would not have significantly impacted
the training provided by the case study presentation.
Entergy also implemented two additional non-CAPR actions to address Root Cause 1:
Present a case study on the root cause to all operations management and
licensed operators to reinforce the standards and expectations for the conduct of
operations during transient conditions (CR-PNP-2016-01621 CA-9)
Present a simulator-based exercise to all licensed operators that reinforces the

responsibilities from EN-OP-115, Conduct of Operations, and Procedure
1.3.34, Operations Administrative Policies and Processes (CR-PNP-2016-
01621 CA-10)
To address Root Cause 2, Entergy implemented a CAPR (CR-PNP-2016-01621 CA-13)

to revise Procedure 1.3.37, Post-Trip Review, to add additional requirements and
information like a challenge meeting, a devils advocate, a technical pre-job briefing,
and operating experience on root cause evaluation CR-PNP-2016-01621.
This root cause evaluation also identified three contributing causes. Of note, some of
the actions Entergy took to address Contributing Cause 2 included establishing an
Enclosure
42
operability determination/functionality assessment improvement action plan and

establishing an industry subject matter expert operability determination/functionality
assessment mentor to provide daily oversight and coaching to senior reactor operators.
Other actions to address operability determination quality were recently completed in
response to apparent cause evaluation CR-PNP-2016-01340. The NRC teams review
and assessment of CR-PNP-2016-01340 is discussed in Section 6.3 of this report.
With respect to the identified causes, the NRC team found that Entergy generally
completed or planned to complete appropriate corrective actions, including CAPRs for
root causes. However, the NRC team noted that although substantial actions have been
taken to address the operability determination process overall, there were not originally
any corrective actions that appeared to specifically address shift manager operability
determination rigor. The NRC team viewed this as a weakness considering the NRC
teams conclusions regarding the importance of this cause. Entergy documented CR-
PNP-2017-00828 to address these concerns. Additionally, during the inspection and as
a result of the NRC teams observations, Entergy planned to take additional action to
conduct operations management face-to-face conversations with shift manager-qualified
individuals to reinforce the shift managers responsibility for operability and functionality
determination accuracy and rigor.
b. IP 95001, Sections 02.03b and 02.04a, require that the inspection staff determine that
corrective actions taken and/or planned have been prioritized with consideration of
significance and regulatory compliance.
With respect to the identified causes, the NRC team found that Entergy generally
prioritized corrective actions taken and planned with consideration of significance and
regulatory compliance.
However, the NRC team noted that none of the substantial actions that have been taken
to address the operability determination process overall were CAPRs, and any re-
evaluation of causes based on significant weaknesses associated with the level of detail
of the CR-PNP-2016-01621 root cause evaluation could impact corrective action plan
prioritization. Procedure EN-LI-118-PNP-RC, 95003 Root Cause Evaluation Process,
defined a CAPR as, An action designed to eliminate or mitigate the root cause to
preclude repetition of the event. Section 5.12, Corrective Action Plan, stated that root
cause evaluations for significant conditions adverse to quality require a CAPR. Hence,
any applicable corrective actions or additional corrective actions to specifically address
shift manager operability determination rigor will need to be prioritized appropriately, and
corrective actions planned to address any root cause revisions will also need to be
prioritized appropriately. Entergy documented CR-PNP-2017-00828 in response to the
NRC teams questions.
c. IP 95001, Sections 02.03c and 02.04b, requires that the inspection staff determine that
corrective actions taken and/or planned to address and preclude repetition of significant
performance issues are prompt and effective.
The CR-PNP-2015-05827 root cause evaluation identified the root cause of SRV-3C not
fully opening as, A Target Rock valve design defect which causes excessive opening
velocity; resulting in a high impact load to the main disc stem and piston when the valve
is actuated on the limited steam flow test stand. To address this root cause, temporary
modification EC 44839 was implemented during Refueling Outage 20, on May 15, 2015,
Enclosure
43
to replace all model 0867F 3-stage SRVs with model 7567F 2-stage valves. During
Refueling Outage 21 in spring 2017, Entergy indicated that they plan to replace the
control assembly in the four existing 2-stage SRVs with new pilot assemblies with coated
discs under work orders 00435308 (A SRV), 00435311 (B SRV), 00435314 (C SRV),
and 00435316 (D SRV). The NRC team determined that these actions were timely and
adequate to correct the specific hardware issues that led to the failure of the A and C
SRVs.
With respect to the causes identified in CR-PNP-2016-01621, the NRC team determined
that these actions were generally timely to correct the identified issues, and the planned
actions to preclude repetition appeared effective and timely if implemented in
accordance with scheduled dates. The NRC team did note, however, that new planned
corrective actions to conduct operations management face-to-face conversations with
shift manager qualified individuals to reinforce the shift managers responsibility for
operability and functionality determination accuracy and rigor need to be completed
promptly, commensurate with their significance. Entergy documented this observation in
CR-PNP-2017-00828. The NRC team also noted that any re-evaluation of causes
based on significant weaknesses associated with the level of detail of the CR-PNP-
2016-01621 root cause evaluation, could necessitate additional actions, which would
need to be completed promptly, to effectively address and preclude repetition of any new
identified performance issues.
d. IP 95001, Section 02.04c, requires that the inspection staff determine that the
appropriate quantitative or qualitative measures of success have been developed for
determining the effectiveness of planned and completed corrective actions.
Entergy scheduled an effectiveness review (EFR) to be completed by October 26, 2017,

for the CAPRs associated with Root Cause 1. This plan included performing a
document review of the licensed operator long-range training plan and a formal simulator
evaluation of each operating crew on the standards and expectations for the conduct of
operations that apply during plant transient conditions. The NRC team determined that
this plan adequately measured success for determining the effectiveness of the CAPRs
to address Root Cause 1.
Entergy also scheduled an EFR for the CAPRs associated with Root Cause 2. The EFR
plan included performing a post-trip review after completing a training simulator
scenario. The NRC team determined that this plan adequately measured success for
determining the effectiveness of the CAPRs to address Root Cause 2. At the time of this
inspection, this EFR had not been completed.
As previously discussed, the NRC team identified multiple points in root cause
evaluation CR-PNP-2016-01621 that demonstrate incorrect conclusions, incorrect
assumptions, and an inadequate rationale for ruling out alternative possible root causes.
The NRC team determined that this was a significant weakness because it ultimately
resulted in Entergys failure to properly assess the impact of the inadequate shift
manager review rigor, as well as any associated causal factors, in root cause evaluation
CR-PNP-2016-01621. Therefore, any root cause revisions will also need to include
quantitative and/or qualitative measures of success for determining the effectiveness of
any CAPRs associated with new or revised root causes. Entergy documented CR-PNP-
2017-00828 in response to the NRC teams conclusions.
Enclosure
44
e. IP 95001, Sections 02.03d and 02.04d, requires that the inspection staff determine that
each Notice of Violation related to the supplemental inspection is adequately addressed,
either in corrective actions taken or planned.
As required by the NRC Reactor Oversight Process Action Matrix, this supplemental
inspection was conducted because a finding of low to moderate safety significance
(White) was identified in the first quarter of 2015. This issue was documented in NRC
Special Inspection Report 05000293/2015007, dated May 27, 2015 (ML15147A412),
and involved Entergys failure to identify, evaluate, and correct the condition of the A
SRVs failure to open upon manual actuation during a plant cooldown on February 9,
2013, which resulted in a similar occurrence when the C SRV did not open upon
manual actuation during a subsequent LOOP event on January 27, 2015. The NRC also
determined that the A SRV had been inoperable for a period greater than the technical
specification allowed outage time of 14 days. At Entergys request, a regulatory
conference was held on July 8, 2015. After considering the information presented by
Entergy at the conference, the NRC maintained that the finding was appropriately
characterized as White, and the results were conveyed to Entergy in a letter dated
September 1, 2015, Final Significance Determination for a White Finding and Notice of
Violation Inspection Report No. 05000293/2015011 PNPS (ML15230A217).
The letter concluded that information regarding: (1) the reason for the violations; (2) the
corrective actions taken and planned to correct the violation and preclude repetition;
and, (3) the date when full compliance was achieved, is already adequately addressed
on the docket in NRC Inspection Report 05000293/2015007, in Entergys presentation at
the July 8, 2015, regulatory conference, and in the letter transmitting the Notice of
Violation.
The NRC team noted that NRC Inspection Report 05000293/2015011, which transmitted
the Notice of Violation, described corrective actions that had been taken in response to
the issue, which included performing an ongoing root cause analysis, continuing
improvements to the site corrective action program, actions to replace the A and C
SRVs in February 2015 (prior to restarting from the January 27, 2015, event), and
replacing all four SRVs with a different model during the Spring 2015 refueling outage.
The NRC team determined that Entergys planned and completed corrective actions
restored compliance with the Notice of Violation of Technical Specification 3.5.E, the
automatic depressurization system was restored to operable when the A and C SRVs
were replaced in February 2015, and replacement of all four SRVs with a different model
during the Spring 2015 refueling outage reasonably addressed the extent of condition
and cause concerns associated with the root cause identified in the evaluation
associated with CR-PNP-2015-05827.
4.6 Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues
Entergy did not request credit for self-identification of an old design issue; therefore, the
issues were not evaluated against the IMC 0305 criteria for treatment of an old design
issue.
Enclosure
45
4.7 NRC Inspection Findings
Failure to Identify All Root Causes of a Significant Condition Adverse to Quality
Introduction. The NRC team identified a Green non-cited violation of 10 CFR Part 50,
Appendix B, Criterion XVI, Corrective Action, because Entergy did not adequately
determine all root causes associated with a significant condition adverse to quality
related to the failure to identify, evaluate, and correct the A SRVs failure to open upon
manual actuation during a plant cooldown on February 9, 2013.
Description. Entergy conducted root cause evaluation CR-PNP-2016-01621 to

determine the causes of the stations failure to identify, evaluate, and correct the A
SRVs failure to open in February 2013. The NRC team determined that the CR-PNP-
2016-01621 root cause evaluation was not conducted to a level of detail commensurate
with the significance of the problem, and identified this as a significant weakness, as
discussed in Section 4.4b of this report. Namely, conclusions and assumptions
throughout the root cause evaluation were incorrect and inconsistent, and the rationale
for ruling out alternative possible root causes was not clear or adequate.
One conclusion that impacted the results of the CR-PNP-2016-01621 root cause
evaluation involved the direct cause and the adequacy of documentation in CR-PNP-
2013-00825. Entergy concluded that the direct cause of the significant performance
issues was, Maintenance, Engineering, Operations, and Condition Review Group
personnel focused evaluation and correction activities on the acoustic monitor for SRV
A instead of the valve because of incomplete information in CR-PNP-2013-00825. The
NRC team reviewed CR-PNP-2013-00825, which was written following the failure of the
A SRV in February 2013. The NRC team determined that the information available in
this CR was sufficient for Entergy to appropriately identify and evaluate A SRV
performance issues and take appropriate corrective actions.
The NRC team noted that the CR-PNP-2016-01621 root cause evaluation identified
contributing causes associated with inadequate operator fundamental training, as it
relates to the operability determination writers use of the steam tables, and
management oversight of the corrective action program and operability determination
process. However, based on interviews conducted by both Entergy and the NRC with
the involved personnel, the NRC team disagreed that the cause of the incorrect
operability determination related to SRV A was training deficiencies that resulted in
poor operator performance while making an operability determination. Rather, the NRC
team concluded that the shift manager, who had the ultimate responsibility to ensure the
operability call was correct, possessed adequate training and knowledge to ensure an
adequate operability determination was completed. The cause of the incorrect and
inadequate operability determination related to SRV A was associated with inadequate
rigor in the shift manager review of an operability determination and any causal factors
that may have impacted the shift managers ability to complete a rigorous review of the
operability determination.
The root cause(s) do not appear to be fully understood because the root cause(s) do not
adequately address inadequate rigor in shift manager review of an operability
determination, which appeared to be the basic causal factor that, if corrected or
eliminated, would preclude repetition of the condition. Additionally, corrective actions
related to Contributing Cause 2 and ongoing operability determination issues addressed
Enclosure
46
operability determination process issues, but did not specifically target shift manager
rigor or any related causal factors that led to the inadequate shift manager rigor. As a
result, Entergy remained susceptible to a repeat occurrence of inadequate shift manager
operability review rigor for any significant condition adverse to quality that was entered
into the corrective action program.
As a result of the NRC teams observations, Entergy planned to take additional action to
conduct operations management face-to-face conversations with shift manager qualified
individuals to reinforce the shift managers responsibility for operability and functionality
determination accuracy and rigor. Entergy documented the NRC teams concerns in the
corrective action program as CR-PNP-2017-00363 and CR-PNP-2017-00828. More
details related to this issue are discussed in Section 4.4b of this report.
Analysis. The NRC team determined that Entergys failure to adequately identify all root
causes associated with a significant condition adverse to quality, the failure to identify,
evaluate, and correct the A SRVs failure to open upon manual actuation during a plant
cooldown on February 9, 2013, was a performance deficiency. The performance
deficiency was more than minor because it was associated with the equipment
performance attribute of the Mitigating Systems cornerstone and if left uncorrected, the
performance deficiency could have the potential to lead to a more significant safety
concern. Specifically, if left uncorrected, the performance deficiency could have the
potential to result in repetition of a failure to identify, evaluate, and correct an SRVs
failure to open or a similar significant condition adverse to quality. The NRC team
system, or component; represent a loss of system and/or function; involve an actual loss
of function of at least a single train or two separate safety systems for greater than its
technical specification-allowed outage time; or represent an actual loss of function of one
or more non-technical specification trains of equipment designated as high safety-
significant. Therefore, the NRC team determined the finding was of very low safety
significance (Green). The NRC team determined that the finding had a cross-cutting
aspect in the area of Human Performance, Avoid Complacency, because individuals did
not recognize and plan for the possibility of mistakes, latent issues, and inherent risk,
even while expecting successful outcomes. Specifically, Entergy incorrectly assumed
that CR-PNP-2013-00825 contained inadequate information to determine that the A
SRV had not opened, and this assumption ultimately impacted the root cause results
documented in CR-PNP-2016-01621 [H.12].
Enforcement. 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, requires,
in part, that in the case of significant conditions adverse to quality, measures shall
assure that the cause of the condition is determined and corrective action taken to
preclude repetition. Contrary to the above, since February 9, 2013, in the case of a
significant condition adverse to quality, measures did not assure that the cause of the
condition is determined and corrective action taken to preclude repetition. Specifically,
Entergy did not establish adequate measures to assure that the cause of a significant
condition adverse to quality, inadequate rigor in shift manager review of operability
determination and its associated causes were adequately determined and corrective
action taken to preclude repetition. As a result, Entergy remained susceptible to a
repeat occurrence of the same significant condition adverse to quality. Entergys
immediate corrective actions included planning to conduct operations management face-
Enclosure
47
to-face conversations with shift manager qualified individuals to reinforce the shift
managers responsibility for operability and functionality determination accuracy and
rigor. Because this violation was of very low safety significance (Green), and Entergy
entered this issue into its corrective action program as CR-PNP-2017-00363 and CR-
PNP-2017-00828, this violation is being treated as a non-cited violation, consistent with
Section 2.3.2.a of the Enforcement Policy. (NCV 05000293/2016011-01, Failure to
Identify All Root Causes of a Significant Condition Adverse to Quality)
5. Controls for Identifying, Assessing, and Correcting Performance Deficiencies (IP

95003, Section 02.02)
5.1 Corrective Action Program Fundamental Problem
5.1.1 PNPS Evaluation Results and Key Corrective Actions
Entergy identified that a significant contributor to the performance problems at the

station was continued demonstration of weaknesses in the implementation of the
corrective action program, which resulted in the station experiencing conditions
adverse to quality and significant conditions adverse to quality that are recurring and
long-standing.
In root cause evaluation CR-PNP-2016-00716, Implementation of Corrective Action

Program, Entergy stated:
Leaders were not exhibiting the corrective action program leadership

behaviors described in the Entergy Nuclear Excellence Model (Policy
EN-PL-100) that was published July 31, 2014Leaders with
corrective action program oversight responsibilities (i.e., [Condition
Review Group, Department Performance Review Meeting/Corrective
Action Review Board and Aggregate Performance Review
Meeting/Self-Assessment Review Board] members) were overly
tolerant of the long-standing and repetitive corrective action program
weaknesses being continuously identified by external departments
and agenciesAs a result, leadership did not establish a sense of
urgency and accountability to correct these inappropriate behaviors
that led to a significant decline in corrective action program
performance.
Entergy identified the following causes in root cause evaluation CR-PNP-2016-

00716:
Direct Cause 1: PNPS personnel have not effectively applied the guidance
contained in the corrective action program procedures and policies. This
resulted in the PNPS corrective action program decline to an unacceptable
level of performance.
Root Cause 1: PNPS leaders have not fostered a sufficient change to the
organizational culture that is needed to improve and sustain corrective action
program performance. As a result, the station continues to experience
longstanding corrective action program shortfalls.
Enclosure
48
Contributing Cause 1: PNPS personnel (Corrective Action Review Group,

Corrective Action Review Board, and Self-Assessment Review Board
members) responsible for performance monitoring and oversight failed to
provide adequate assessment of corrective action program performance.
This contributed to leadership not recognizing the need for additional action
to mitigate the corrective action program performance decline.
Contributing Cause 2: PNPS personnel who initiate, disposition, and approve

corrective action program products have not received adequate training
commensurate with their corrective action program roles and responsibilities.
This has resulted in unacceptable quality of some corrective action program
products.
Contributing Cause 3: PNPS leadership has not effectively managed the

resources to implement and sustain the corrective action program. This
resulted in declining corrective action program performance for the
identification, evaluation and resolution of station issues.
Entergy implemented a number of actions to improve corrective action program

performance including training personnel, improving program oversight, and hiring
external corrective action program subject matter experts and mentors to bridge the
performance gaps until station personnel could perform at appropriate levels. Key
corrective actions developed by Entergy included:
CR-PNP-2016-00716 CA-74: (CAPR-1) Augment the station staff with a

subject matter expert; who has at a minimum, working experience as a Site
Vice President direct report at an operating nuclear power plant or equivalent
experience, to mentor the individual behaviors and station culture supporting
the corrective action programs. This subject matter expert must have the
organizational authority and independence to report on corrective action
program performance to the station directors, vice president, and fleet
executives; therefore, the subject matter expert will organizationally report to
the Station Vice President and will provide a minimum of one on-site visit per
month. The position will monitor, coach, and report the behaviors of station
individuals responsible for the corrective action program product review and
approval functions. Corrective action program quality performance indicator
results will be monitored and tracked by the subject matter expert. This
function will remain in place until the end of plant operating life.
CR-PNP-2016-00716 CA-78: (CAPR-2) Develop and implement monthly

corrective action program performance indicators including station and
department level indicators to monitor performance including a monthly
required review by the Corrective Action Review Board.
CR-PNP-2016-00716 CA-80: Assign a part time (two weeks per month)

subject matter expert to coach and mentor department performance
improvement coordinators and corrective action program performance and
independently review root cause evaluations and apparent cause evaluations
to acquire the data for populating the Corrective Action Program Performance
Indicators.
Enclosure
49
CR-PNP-2016-00716 CA-81: Assign a part time (two weeks per month)

subject matter expert to coach and mentor personnel who implement the
operating experience, trending, and self-assessment and benchmarking
processes.
CR-PNP-2016-00716 CA-96: Generate the corrective action program subject

matter expert monthly status report. These monthly status reports must
continue until end of plant operating life.
5.1.2 NRC Inspection Scope
The NRC team reviewed and assessed the Corrective Action Program Fundamental
Problem, as documented in root cause evaluation report CR-PNP-2016-00716,
Implementation of Corrective Action Program, and supporting documents. The
NRC team reviewed documentation, interviewed station staff, attended station
corrective action program meetings, and, as applicable, conducted walkdowns of
plant structures, systems, and components to assess the stations performance in
the following specific areas:
Review root cause evaluation CR-PNP-2016-00716 and assess whether

identified direct cause(s), root cause(s), and contributing cause(s) were
appropriate
Review and assess the implementation of root cause evaluation CR-PNP-

2016-00716 interim actions, CAPR-1, and CAPR-2
Review and assess the adequacy and implementation of EFRs for CAPR-1
and CAPR-2 (including interim reviews)
Review and assess implementation of the cause evaluation process
Review and assess the work order backlog for any significant conditions
adverse to quality or conditions adverse to quality that may have been closed
to a work order
Review and assess implementation of the trending and performance review

process
On a sampling basis, conduct walkdowns of plant equipment referenced in

reviewed corrective action program documents to evaluate problem
identification, assessment, and corrective action completion
Review and assess the use of the corrective action program during recovery
evaluations
Review and assess corrective action program staffing and training adequacy
Review and assess corrective action program accountability and

setting/enforcing expectations
Enclosure
50
The NRC team also reviewed and assessed the effectiveness of audits and
assessments performed by the Nuclear Independent Oversight (NIOS) group, line
organizations, and external organizations. The NRC team reviewed documentation,
interviewed station staff, and attended station corrective action program meetings to
assess the stations performance in the following specific areas:
The use of the Learning Organization process to track and document

completion of recommendations, as compared to use of the condition
reporting process
The relative rigor of assessments performed at PNPS by the Entergy fleet
The use of benchmarking outside the fleet to assess station performance
The timeliness and specific responses to audits and assessments performed

at PNPS by external organizations
5.1.3 NRC Inspection Observations and Assessment
The NRC team reviewed the causes Entergy identified in root cause evaluation CR-
PNP-2016-00716 and the analysis methodologies that Entergy utilized to arrive at
those conclusions. The NRC team determined that the identified direct cause, root
cause, and contributing causes were reasonable and supportable. However, the
NRC team noted that the root cause focused on the station senior leadership and
failed to adequately address the role that lower-level leaders had in the
implementation of the day-to-day prioritization and resolution of corrective action
program items. The NRC team determined that Entergys definition of leaders
associated with the root cause was too narrow, and failed to recognize that
department performance improvement coordinators had a significant leadership role
in the implementation and assessment of the corrective action program.
The NRC team reviewed the corrective actions associated with the Corrective Action
Program Fundamental Problem root cause evaluation; specifically focusing on
interim actions Entergy implemented to address short term vulnerabilities and
CAPRs, which were designed to eliminate or mitigate the root cause to preclude
repetition of the event.
Entergys interim corrective actions included:
Coaching of station leaders assigned as Condition Review Group members

and the department improvement coordinators on conservative decision-
making behaviors related to the corrective action program. This coaching
was performed by the Director of Regulatory and Performance Improvement.
Instituting a cause evaluation subject matter expert who mentored and

independently reviewed all cause evaluation products
Instituting a corrective action program subject matter expert who coached

and mentored the department performance improvement coordinators and
Condition Review Group members
Enclosure
51
Instituting support corrective action program subject matter experts to

perform closure reviews of corrective actions
Instituting a subject matter expert who coached and mentored personnel who
implement the operating experience, trending, and self-assessment and
benchmarking programs.
The NRC team determined that these interim actions were appropriate for
addressing the short term vulnerabilities that the site identified as major weaknesses
in the implementation of the corrective action program. Based on the observations
and interviews with site personnel, the NRC team found that individuals still relied
heavily on the subject matter experts as backstops to ensure quality
implementation of the corrective action program process to prevent issues from
recurring. As such, the NRC team concluded that plant personnel behavioral
improvements were still warranted in the fundamental areas of problem identification,
evaluation, and resolution while these subject matter experts fulfilled their assigned
(interim) functions. The interim actions were still in place at the conclusion of the on-
site inspection.
From the root cause evaluation report, CAPR-1 was to augment the station staff with
a subject matter expert who is responsible for monitoring, coaching, and reporting
behaviors of station individuals responsible for the corrective action program product
review and approval functions. CAPR-2 was to develop monthly corrective action
program performance indicators, including station and department level indicators, to
monitor performance. These indicators would be reviewed by the members of the
Corrective Action Review Board and the subject matter experts to identify trends in
station performance in the corrective action program.
Subsequent to the arrival of the 95003 NRC team, Entergy issued a revision to EN-
LI-102, Corrective Action Program. The revised process combined the functions of
the Corrective Action Review Board and Condition Review Group into a new
Performance Improvement Review Group. The NRC team determined that this
change in process did not affect the CAPRs, as the subject matter expert and subject
matter expert support personnel have continued to perform their assigned corrective
action program oversight functions, including those related to the new Performance
Improvement Review Group.
The NRC team conducted document reviews, observations, and interviews with
station personnel to determine if the CAPRs, as written, would address the root
cause of station leaders not fostering sufficient change to the organizational culture
to improve and sustain corrective action program performance. As described in
Entergy procedure EN-LI-118, Cause Evaluation Process, corrective actions should
be specific, measurable, achievable, realistic, and timely. Also, EN-LI-118 noted that
effective corrective actions will eliminate the causes of problems, strengthen or refine
existing processes or barriers (if deemed acceptable), significantly reduce the
probability of occurrence of the same/similar events, and are clearly sustainable for
long-term correction of the issue. After in-depth reviews and conversations with
Entergy, the NRC team concluded that, as designed, CAPR-1 and CAPR-2 did not
appear adequate to fully correct the root cause and preclude repetition of the
fundamental problem, as described below.
Enclosure
52
CAPR-1, as it was initially implemented, provided for the corrective action program
subject matter expert to mentor/coach director-level PNPS personnel, and use the
performance indicators (CAPR-2) as a tool to measure effectiveness. The
mentoring/coaching was intended to then trickle down to the manager and
supervisor positions through one-on-one coaching between the PNPS directors and
their subordinates. The corrective action program support subject matter experts, as
described in the interim actions, provided independent reviews and focused
feedback of corrective action program products during corrective action program
meetings. However, while the support subject matter expert role was integral to the
implementation of CAPR-1, Entergy did not include the support subject matter
experts in CAPR-1, but rather as a separate non-CAPR corrective action that could
be closed following a successful EFR.
The NRC team noted that the department performance improvement coordinators,
as individuals on-site who were responsible for implementing significant parts of the
corrective action program, were not addressed in the CAPR to receive the corrective
action mentoring/coaching function. Also absent from receiving systematic direct
mentoring/coaching were the Performance Improvement Review Group members
(department managers and supervisors), who also have responsibilities to implement
the corrective action program. Instead, Entergy believed that the performance of
these members could improve through internal mentoring/coaching from their
respective department directors.
Through interviews with various Entergy personnel, the NRC team determined that
Entergy did not implement a systematic or structured coaching/mentoring process to
reach all station personnel with leadership responsibilities in the implementation of
the corrective action program. Additionally, the feedback that was provided to the
department performance improvement coordinators and the Performance
Improvement Review Group members from the support subject matter experts was
solely focused on whether corrective action program products and meetings met the
process, and did not involve coaching or mentoring on how performance could be
improved. Additional discussion with Entergy staff indicated that there was an
expectation that corrective action program staff receiving focused feedback would,
as desired, seek coaching/mentoring to address the feedback provided. Considering
the weaknesses identified in most areas of both the Third Party Nuclear Safety
Culture Assessment and the NRCs independent safety culture assessment (Section
7.2), and interviews conducted with Entergy personnel, the NRC team determined
that there was not a basis or any evidence to support a conclusion that corrective
action program staff would independently seek coaching or mentoring to address this
feedback. Therefore, because of the apparent weaknesses in safety culture at
PNPS and because Entergy did not develop any formal planned and systematic
actions to ensure that performance would be improved for all key individuals who
implement the corrective action program, the team determined that CAPR-1 and
CAPR-2 did not provide reasonable assurance that improvements in the stations
execution of the corrective action program would be continued and sustained.
During the NRC team inspection, Entergy revised the CAPRs and other corrective
actions for the Corrective Action Program Fundamental Problem root cause
evaluation. In summary, Entergy changed CAPR-1 to encompass the support
subject matter expert functions and to more clearly define how the subject matter
experts would accomplish the objectives of monitoring, coaching, and reporting.
Enclosure
53
CAPR-1 and CAPR-2 are intended to remain in place through the end of plant life.
Also, Entergy initiated an interim corrective action to coach and mentor the
department performance improvement coordinators. Additional detail was added to
this action to ensure the department performance improvement coordinators
received appropriate mentoring and coaching on a one-on-one and group basis to
aid in the changing of behaviors. Though this corrective action was appropriate, the
NRC team noted that it was not part of the CAPR-1 actions, but rather, was
designated as an interim action.
The NRC team reviewed the changes and conducted additional interviews with
Entergy on the revisions. The NRC team noted that the new CAPR-1, as written,
provided extensive guidance on the execution of the monitor and report functions for
the subject matter experts. However, the NRC team noted that the coaching function
still lacked specific execution guidance and it was unclear to the NRC team how
sustainable that piece of the CAPR would be to continue to foster improvements.
The root cause evaluation specifically listed attributes that Entergy determined were
contributory to the root cause of station leaders not exhibiting the appropriate
behaviors for corrective action program excellence. These attributes ranged from
insufficient knowledge to resource management to accountability and were all items
that would be addressed with the coaching/mentoring function provided by the
subject matter experts. It was not evident, based on interviews and document
reviews, that the coaching/mentoring would be robust enough to ensure
comprehensive and sustainable improvements in those areas.
The NRC team also noted that the changes to the interim corrective actions for the
department performance improvement coordinators did not provide an adequate
means of communicating learnings between the manager-level positions
(Performance Improvement Review Group members) and the department
performance improvement coordinators; both of which have responsibilities for
different, but integrated pieces of the corrective action program. A work task, WT-
PNP-2016-435, was created to track cross-communication and observations for
these groups through the beginning of the next refueling outage in spring 2017. The
NRC team noted that this work task was of short duration and was not tied to
successful completion of an EFR to ensure the proper behaviors and learnings were
gained as desired.
Overall, the NRC team determined that while the station had noted improvement in
corrective action program performance, CAPR-1 and CAPR-2, as they were written
and implemented, did not provide reasonable assurance that any improvement could
be continued and sustained. Specifically, the lack of a systematic approach for
coaching/mentoring of Performance Improvement Review Group and department
performance improvement coordinators would likely inhibit effective continuation of
any performance improvements. Additionally, though Entergy implemented interim
corrective actions to coach and mentor the department performance improvement
coordinators, the NRC team noted that this action was not designated as a CAPR.
The NRC team documented a finding related to this issue in Section 5.1.4 of this
report.
The NRC team reviewed Entergys completed interim EFRs for CAPR-1, CAPR-2,
and the EFR for non-CAPR corrective actions associated with the Corrective Action
Program Fundamental Problem root cause evaluation. For EFR-1 related to
Enclosure
54
CAPR-1, Entergy performed a focused self-assessment with a goal of determining if

station personnel behaviors supported corrective action program product quality and
illustrated nuclear safety culture and excellence model attributes. This was
accomplished by interviewing personnel, reviewing corrective action program
performance indicators, and looking for improving trends in corrective action program
product quality for the months of July and August 2016. The EFR-1 interim review
was combined with the focused self-assessment, EFR-2, performed for CAPR-2.
EFR-2 specifically reviewed the corrective action program performance indicators to
ensure the results were reflective of current corrective action program behaviors and
practices and that they are being used to improve corrective action program
performance.
Overall, Entergy concluded that the implementation of CAPR-1 and CAPR-2 was in
accordance with the corrective actions as described in the root cause evaluation and
the CAPRs were determined to be effective at the interim review. Improvements in
corrective action program performance were recognized in several areas such as
cause evaluation quality, corrective action program meeting quality, and the overall
quality of corrective action closures. Improvements were determined to still be
needed in the areas of self-identification of problems, benchmarking and self-
assessments, and initial screening of CRs. Also, a check and adjust of the
performance indicators occurred in August 2016 based on recommendations from
the subject matter experts. Additional run time was determined to be needed to
ensure the indicators were providing the appropriate data. However, CAPR-2 was
still deemed to be effective by Entergy at the interim review.
The NRC team determined that these interim EFRs were narrow in scope and
conducted too soon after the corrective actions were implemented, in that there was
not sufficient data to support Entergy conclusions. Specifically, Entergy implemented
the CAPR actions in June 2016 and the EFRs looked at data from July and August
2016. The initial plan for the EFRs stated they would be performed approximately
five months after implementation of the corrective actions. This did not occur. Also,
after collecting the first round of data for the CAPR-2 performance indicators in July
2016, Entergy changed the indicators in August 2016.
In addition, as part of the EFRs, Entergy reviewed 30 CRs written in July and August
for timeliness and closure quality, two root cause evaluations, and four apparent
cause evaluations. The NRC team observed that this review was a limited sample of
CRs generated over the two-month time period; PNPS generates approximately that
number of CRs daily. Also, the NRC team identified CRs that were written after this
EFR was completed that indicated many deficiencies still existed in the timeliness
and quality of CR closures. The NRC team and resident inspectors performed
independent reviews of the root and apparent cause evaluations listed in the EFR
and found multiple deficiencies associated with those evaluations.
For example, the inadequacies of one of the cause evaluations conducted for an
equipment issue was documented as a subsequent NRC-identified non-cited
violation in the fourth quarter 2016 NRC integrated inspection report. The resident
inspectors documented a Green non-cited violation (NCV 2016004-03) of 10 CFR
50.65(a)(4) because Entergy did not properly assess and manage the increase in
risk due to performing protective relay calibration and functional testing associated
with the shutdown transformer on seven occasions from December 9, 2005, through
Enclosure
55
August 27, 2014. Specifically, Entergy did not identify that the performance of
calibration and functional testing of protective relays associated with the shutdown
transformer would prevent the 4160V safety buses from being automatically powered
by other required sources, and consequently, did not properly assess and manage
the increase in risk. The resident inspectors reviewed the associated root cause
evaluation (CR-PNP-2016-02735) and determined that the evaluation did not
address the issue with risk assessment or application of technical specification
limiting conditions for operation. Additionally, the resident inspectors noted a
timeliness issue with the root cause evaluation, potentially due to issues with
classification of the CR. Though the testing issue was identified in April 2016,
Entergy did not start the cause evaluation until June 2016. This issue is discussed in
more detail in NRC Inspection Report 05000293/2016004 (ML17045A524).
The NRC team also noted another example that was missed by the individuals
conducting the EFR. On May 5, 2016, the unit commenced a rapid power reduction
due to heavy traveling screen fouling and rising screen differential pressures.
Entergy documented this issue in CR-PNP-2016-03204, which was originally
classified as a B significance level, and would have required an apparent cause
evaluation to assess the issue. NRC team interviews with the corrective action
program subject matter experts indicated that the subject matter experts determined
that the issue should have been classified as an A significance level, which would
have required a root cause evaluation. The station decided to leave the significance
as a B and completed an equipment apparent cause evaluation for the issue.
Though the individuals conducting the EFR determined that there were no issues
with this apparent cause evaluation, the Corrective Action Review Board later
determined that the cause analysis was incorrect.
Based on the interim effectiveness reviews being narrow in scope, and the results of
the NRCs independent reviews of the cause evaluations listed in the EFR, the NRC
team determined that the interim EFRs conducted for CAPR-1 and CAPR-2 were not
conducted with the appropriate breadth and depth to illustrate interim effectiveness
of those corrective actions related to the Corrective Action Program Fundamental
Problem. Entergy documented these observations in CR-PNP-2017-00339, and is
expected to re-evaluate the future planned final EFRs, EFR-4 and EFR-5, based on
those reviews being structured similar to EFR-1 and EFR-2.
5.1.4 NRC Inspection Findings
Failure to Establish Corrective Actions to Preclude Repetition of a Significant

Condition Adverse to Quality
Introduction. The NRC team identified a Green non-cited violation of 10 CFR Part
50, Appendix B, Criterion XVI, Corrective Action, because Entergy did not take
corrective action to preclude repetition for a significant condition adverse to quality
identified in root cause evaluation CR-PNP-2016-00716, Implementation of the
Corrective Action Program, Revision 2. Specifically, the NRC team identified that
corrective actions to prevent repetition of Entergys continued weaknesses in the
implementation of the corrective action program were inadequate.
Description. During performance of the collective evaluation process, Entergy

identified the corrective action program as a fundamental problem. As a result,
Enclosure
56
Entergy completed a root cause evaluation and documented the results in CR-PNP-
2016-00716, Implementation of the Corrective Action Program, Revision 2.
Entergy documented the following in CR-PNP-2016-00716:
Problem Statement: PNPS continues to demonstrate weaknesses in the

implementation of the corrective action program. The station is experiencing
conditions adverse to quality and significant conditions adverse to quality
which are recurring and longstanding.
Root Cause: PNPS leaders have not fostered a sufficient change to the
organizational culture that is needed to improve and sustain corrective action
program performance. As a result, the station continues to experience
longstanding corrective action program shortfalls. PNPS leaders are not
exhibiting the corrective action program leadership behaviors described in the
Entergy Nuclear Excellence Model (Policy EN-PL-100) that was published
July 31, 2014. Leaders with corrective action program oversight
responsibilities (Condition Review Group, Department Performance Review
Meeting/Corrective Action Review Board, and Aggregate Performance
Review Meeting/Self-Assessment Review Board members) have been overly
tolerant of the long-standing and repetitive corrective action program
weaknesses. PNPS leadership did not have the requisite knowledge and
skills for the corrective action program performance standards.
CAPR-1: (summary) Augment the station staff with a subject matter expert.
The position will monitor, coach, and report behaviors of station individuals
responsible for the corrective action program product review and approval
functions. Corrective action program quality performance indicator results will
be monitored and tracked by the subject matter expert. The intent of this
action is to provide the station with a subject matter expert to mentor the
corrective action program.
CAPR-2: (summary) Develop monthly corrective action program

performance indicators including station and department level indicators to
monitor performance including a monthly required review by the Corrective
Action Review Board. The intent of this action is to provide a monitoring tool
for detection of corrective action program performance trends at the
department level.
CA-80: (summary) Assign a part-time (two weeks per month) subject matter
expert to coach and mentor department performance improvement
coordinator and corrective action program performance and independently
review root and apparent cause evaluations to acquire the data for populating
the corrective action program performance indicators.
The NRC team identified that implementation of CAPR-1 and the associated
supporting corrective actions resulted in a system where director-level and some
select manager-level positions received corrective action program-focused coaching
from the corrective action program subject matter expert, with the expectation that
this focused coaching would trickle down to the subordinate manager and
supervisor levels. Through interviews with station staff, the NRC team identified that
Enclosure
57
focused coaching at the manager and supervisor level was mainly from the
corrective action program support subject matter experts providing independent
review and focused feedback on corrective action program products and the conduct
of corrective action program meetings. However, while this support subject matter
expert role was integral to the implementation of CAPR-1, Entergy did not include the
support subject matter experts in CAPR-1, but rather as a separate non-CAPR
corrective action (CA-80) that could be closed following a successful EFR.
While subject matter expert coaching should improve performance of senior

leadership, the NRC team did not identify any systematic process to coach all station
individuals responsible for corrective action program product review and approval
functions, such as the department performance improvement coordinators and the
Performance Improvement Review Group members. Subsequent interviews with
Entergy staff responsible for the root cause evaluation indicated that there was an
expectation that corrective action program staff receiving focused feedback (CA-80)
would, as required, seek coaching to correct the deficiencies identified. Considering
the weaknesses identified in most areas of both the Third Party Nuclear Safety
Culture Assessment and the NRCs independent safety culture assessment (Section
7.2), and interviews conducted with Entergy personnel, the NRC team determined
that there was no evidence to support that this expectation would be satisfied. The
NRC team concluded that absent a systematic or structured coaching/mentoring
process to reach all personnel with leadership responsibilities in the implementation
of the corrective action program, CAPR-1 would not adequately address the
deficiencies identified in the root cause and would not provide reasonable assurance
that improvements seen in implementation of the corrective action program would be
continued and sustained.
Analysis. The NRC team determined that Entergys failure to establish measures to
preclude repetition of a significant condition adverse to quality in accordance with 10
CFR Part 50, Appendix B, Criterion XVI, Corrective Action, was a performance
deficiency. Specifically, in development of CAPR-1, Entergy did not include a
systematic or structured process to coach/mentor all personnel with leadership
responsibilities in implementation of the corrective action program. The performance
deficiency was more than minor because if left uncorrected, it had the potential to
lead to a more significant safety concern. Specifically, the failure to preclude
repetition of this significant condition adverse to quality could result in continuing
weaknesses in implementation of the corrective action program, which was
designated as a fundamental problem, and thus a contributing factor for PNPS
Column 4 performance. Additionally, weaknesses with corrective action program
implementation could result in equipment issues where operability is not maintained
(e.g., see Section 5.3.3). The NRC team evaluated the finding using Exhibit 2,
Mitigating Systems Screening Questions, of IMC 0609, Appendix A, Significance
Determination Process for Findings At-Power, and determined this finding did not
affect the design or qualification of a mitigating structure, system, or component;
represent a loss of system and/or function; involve an actual loss of function of at
least a single train or two separate safety systems for greater than its technical
specification-allowed outage time; or represent an actual loss of function of one or
more non-technical specification trains of equipment designated as high safety-
significance (Green). The NRC team determined that the finding had a cross-cutting
aspect in the area of Human Performance, Procedure Adherence, because
Enclosure
58
individuals did not follow processes, procedures, and work instructions. Specifically,
Entergy did not follow procedure EN-LI-102, which provides the station standards for
crafting a corrective action and states, in part, that the corrective action descriptions
must be worded to ensure that the adverse condition or cause/factor is addressed
[H.8].
Enforcement. 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action,

requires, in part, that in the case of significant conditions adverse to quality,
measures shall be established to ensure that corrective action is taken to preclude
repetition. Contrary to the above, beginning in November 2016, in the case of a
significant condition adverse to quality, Entergy failed to establish measures to
ensure that corrective action was taken to preclude repetition. Specifically, in the
case of the corrective action program fundamental problem, a significant condition
adverse to quality, Entergy failed to establish adequate CAPRs. Because this finding
is of very low safety significance (Green) and has been documented in the corrective
action program as CR-PNP-2017-00053, CR-PNP-2017-00410, and CR-PNP-2017-
01134, this violation is being treated as a non-cited violation, consistent with Section
2.3.2.a of the Enforcement Policy. (NCV 05000293/2016011-02, Failure to
Establish Corrective Actions to Preclude Repetition of a Significant Condition
Adverse to Quality)
5.2 Corrective Action Program Accountability and Expectations
The NRC team performed direct observation of Entergy meetings that were
associated with the implementation of the corrective action program to assess the
establishment and reinforcement of site standards and expectations related to the
corrective action program, and accountability of site personnel who have
responsibility for implementation of the corrective action program. The NRC team
observed the Work Request Screening Committee meetings, the Condition Report
Prescreening meetings conducted by the department performance improvement
coordinators, and the Performance Improvement Review Group meetings.
The Work Request Screening Committee meeting performed reviews of CRs

assigned to work requests for appropriate prioritization and scheduling. Entergy
assigned work request priority based on whether the work request was associated
with a condition adverse to quality or a non-adverse condition. Additionally, Entergy
assessed the level of degradation or non-conformance of the equipment problem to
be repaired and considered the safety significance of the issue.
During an observation of the Work Request Screening Committee meeting, the NRC
team noted an interaction between members of the screening committee related to a
concern that multiple open historic deficient conditions adverse to quality had been
misclassified in the work request process. This resulted in the failure to appropriately
schedule the items for maintenance. The NRC team identified that this concern was
not entered into the corrective action program, so that the concern could be fully
assessed. Some members of the screening committee felt that it was not necessary
to enter the concern into the corrective action program since the screening
Enclosure
59
committee was capable of assessing the priority independently. It was noted that
one of the subject matter experts, who was also observing the meeting, provided
immediate feedback that the concern needed to be entered into the corrective action
program in accordance with Entergy procedures. In this instance, the subject matter
expert needed to reinforce the appropriate corrective action program behavior for site
personnel.
The Condition Report Prescreening meetings conducted by the department

performance improvement coordinators reviewed CRs entered into the corrective
action program. Each department performance improvement coordinator pre-
populated this information in the CRs for their respective departments based on their
knowledge of the corrective action program and input received from their manager.
The pre-populated information was then discussed and concurred on by all the
department performance improvement coordinators at the prescreening meeting.
This information was used to assign priority, classification, and trending codes for
each CR reviewed.
The NRC team noted, during observation of these meetings, that some CRs were
assigned as bring-back items due to insufficient understanding of the issue or not
having consensus among the department performance improvement coordinators.
The NRC team noted that in some cases, this is a good practice. However,
excessive use of bring-backs could delay review and approval of a CR by the
Performance Improvement Review Group and could unnecessarily delay corrective
actions. The NRC team did not identify any specific concerns of untimely corrective
actions as a result of excessive bring-backs. However, this practice was not in
accordance with station expectations on the timeliness of classification and review of
CRs. This expectation was unwritten and the NRC team noted that it could be
emphasized more, or written as a standard, to ensure issues are reviewed in a timely
manner.
The Performance Improvement Review Group meeting performed screening of CRs

subsequent to the department performance improvement coordinator prescreening
meeting. The Performance Improvement Review Group provided final review and
approval of the recommendations given at the prescreening meeting. Additionally,
the Performance Improvement Review Group provided oversight of operability
determinations and review and approval of select cause evaluations. The
Performance Improvement Review Group meeting was typically chaired by the
General Manager for Plant Operations and attended by the Performance
Improvement Director, Operations Manager, Engineering Director, and other
department managers as necessary based on the meeting agenda.
The NRC team noted during observation of these meetings, and through interviews
with Performance Improvement Review Group members, that attendance by
department managers was inconsistent for those departments that were not required
for quorum purposes. Additionally, active participation by department managers in
the meeting was limited to only those items that directly related to their work groups.
Collegial discussion and consensus of CRs was not observed by the NRC team to
the level that was observed during the department performance improvement
coordinator prescreening meetings. Alternately, the Performance Improvement
Review Group was structured more as a meeting between the Performance
Enclosure
60
Improvement Review Group chairperson and the Performance Improvement

department with others providing input when directly questioned.
The NRC team discussed with Entergy their observations of inconsistent attendance
and lack of engagement by non-quorum department managers. Due to the lack of
structured coaching/mentoring of Performance Improvement Review Group
members and department managers (discussed in Section 5.1.3), not all
Performance Improvement Review Group members were receiving the same level of
feedback and learning opportunities. Additionally, coaching/mentoring opportunities
disseminated during one Performance Improvement Review Group meeting were not
formally captured or disseminated to members that were not in attendance. As such,
these potentially represent lost learning opportunities that could be discussed when
managers and department performance improvement coordinators meet before their
prescreening meetings. The NRC team determined that this further illustrated the
need for Entergy to develop a structured, systematic approach to
coaching/mentoring all corrective action program leaders to ensure improvements
are sustainable.
The NRC team noted, through discussions with the PNPS Performance
Improvement Manager and the 95003 Recovery Director, that Entergy acknowledged
that many of the corrective actions to improve station personnel accountability and
standards are still in progress. During interviews with the department performance
improvement coordinators, and those that routinely attend the Performance
Improvement Review Group meetings, the NRC team heard that there has been
more constructive engagement of personnel in the meetings. However, as
evidenced by the observations above, personal accountability and adherence to
station and fleet standards should continue to remain a recovery focus area.
No findings were identified.
5.3 Implementation of the Cause Evaluation Process
The NRC team performed a review of a sample of root cause evaluations and
apparent cause evaluations that were completed after the implementation of the
Corrective Action Program Fundamental Problem root cause evaluation CAPRs and
interim corrective actions. The NRC team focused the review on cause evaluation
process and quality in accordance with Entergy procedure EN-LI-118, Cause
Evaluation Process, and EN-LI-102, Corrective Action Program. This review
facilitated an assessment of the effectiveness of the interim corrective actions to
improve cause evaluation quality. These actions included hiring contract personnel
to perform root and apparent cause analyses, with supplemental help from site
personnel as needed, and assignment of a subject matter expert to review the causal
evaluation products for quality once completed. Root and apparent cause
evaluations directly associated with the fundamental problems and problem areas for
the 95003 and 95001 inspections were included in this review.
Enclosure
61
Based on a sampling of root and apparent cause evaluations conducted between

July and December 2016, the NRC team determined that overall, the interim
corrective actions from the corrective action program root cause evaluation appeared
to have generally improved the quality of root cause and apparent cause evaluations.
However, the NRC team identified deficiencies and gaps in several of the cause
evaluations that were reviewed. Common deficiencies and areas for continued
improvement were identified in the following parts of the cause evaluation process:
adequacy and timeliness of corrective actions/CAPRs; the scope and timeliness of
EFRs; rigor of completing and assigning corrective actions to extent of condition
reviews; and the use of industry operating experience and missed opportunity
reviews (for root cause evaluations). Specific examples of these deficiencies were
cited in the violations identified during this inspection or are discussed below. Those
observations that did not rise to the level of findings were discussed with PNPS and
CRs were generated to address the gaps.
The NRC team identified two issues associated with implementation of the cause
evaluation process. Specifically, as previously discussed, the NRC team noted
multiple points in the CR-PNP-2016-01621 root cause evaluation, Revision 2, that
demonstrate incorrect conclusions, incorrect assumptions, that the rationale for ruling
out alternative possible root causes was not clear or adequate, and why the
evaluation did not appropriately consider other possible root causes. This was
identified as a significant weakness. The NRC team also identified other
weaknesses associated with the CR-PNP-2016-01621 root cause evaluation in the
use of systematic methodologies, operating experience reviews, extent of condition,
safety culture aspects reviews, and corrective actions planned and taken. (See
Section 4 for additional details).
The NRC team also identified a Green finding because Entergy failed to issue
adequate CAPRs associated with a root cause of the feedwater regulating valve
failure in September 2016 that resulted in a manual scram. Additional details
concerning this finding are discussed below.
Failure to Issue Appropriate Corrective Actions to Preclude Repetition for the Causes
of the September 2016 Scram
Introduction. The NRC team identified a Green finding because Entergy did not
issue appropriate CAPRs in accordance with EN-LI-102, Corrective Action Process,
Revision 28. Specifically, Entergy did not issue adequate CAPRs associated with
Root Cause 1 of the feedwater regulating valve failure in September 2016 that
resulted in a manual scram.
Description. On September 6, 2016, with reactor power at 91 percent, control room

operators noticed unexpected instantaneous core thermal power changes and then
feedwater flow oscillations. Operations determined that a problem existed with
feedwater regulating valve A and entered Procedure 2.4.49, Feedwater
Malfunctions. Operators placed feedwater regulating valve A in remote manual to
attempt to stabilize the feed flow oscillations, but no effect was noted. Power
Enclosure
62
changes of up to 5 percent were seen on core neutron monitors, and operators were
dispatched to the condenser bay and attempted a manual lockup of feedwater
regulating valve A (FRV-642A). The manual locking device was degraded due to
significant corrosion, so feedwater regulating valve A could not be manually locked.
Control room operators scrammed the reactor when reactor water level benchmarks
were reached, and the main steam isolation valves closed on a Group 1 isolation
signal. Entergy ultimately determined that a loose wire connection affected the
digital control system, which resulted in loss of feedwater regulating valve control in
both automatic and remote-manual modes of operation. (See NRC Inspection
Report 05000293/2016004 (ML17045A524)) for additional discussion on the
technical aspects of this issue.)
Entergy conducted a root cause evaluation for this event in CR-PNP-2016-06635.

Entergy identified two root causes:
Root Cause 1: Some planning personnel do not always know or understand

work order planning standards documented in EN-FAP-WM-011, Work
Planning Standard, when including vendor or technical manual information in
work orders.
Root Cause 2: The site air operated valve test procedure for FV-642A/B was
less than adequate in identifying degradation in the valve stem and packing
performance.
The root cause evaluation also discussed the stations review of planning procedures
that are used when generating work orders. The root cause evaluation stated, This
review identified that requirements of Section 3.7 of procedure [EN-]FAP-WM-011 as
it relates to use of vendor manuals was not specifically followed as information from
the vendor manual was not added to the work instructions in the [work order].
Entergy documented two causal factors in the root cause evaluation that were
combined to develop Root Cause 1:
Maintenance planning procedure EN-FAP-WM-011 was not followed when

developing detailed work instructions for wire assembly and installation which
used vendor manual information.
Critical maintenance work order planning standards when including vendor or

technical manual information were not always known or understood by some
planning personnel.
To address Root Cause 1, CR-PNP-2016-06635 identified CAPR-1, with two options.

The following was excerpted from Entergys root cause evaluation:
Create and issue a site-specific procedure to implement a checklist to be

used for critical maintenance work orders to verify the correct use of vendor
and technical information as per the requirements of EN-FAP-WM-011 and
expectations of maintenance and planning departments
Enclosure
63
Revise existing fleet procedure EN-FAP-WM-011, documenting within the

procedure that Section 3.7 is the CAPR together with revising Attachment
7.2, Work Package Quality Checklist, and requiring the planners to use the
checklist on all critical maintenance work packages.
Additional non-CAPR corrective actions to address Root Cause 1 included

implementing CAPR-1, applying the CAPR-1 checklist to all critical maintenance
work orders that are currently planned and not implemented, communications to
reinforce procedure use and adherence expectations, and a one-time training to
qualified planners and project planners on EN-FAP-WM-011.
The NRC team noted that Section 5.8[2](a)(1) of EN-LI-102, Corrective Action
Process, Revision 28, stated that the responsible manager must, Ensure that a
Root Cause Analysis is performed for Category A CRs utilizing NMM EN-LI-118,
Root Cause Analysis Process, and that appropriate CAPRs are issued. The NRC
team reviewed the root cause evaluation and interviewed Entergy personnel involved
in drafting the root cause evaluation. The NRC team questioned how the corrective
action plan, as written, would preclude repetition of Root Cause 1 and how CAPR-1
was sustainable. During interviews, Entergy personnel made clear that their view
was that EN-FAP-WM-011, an informational use procedure, was adequate and
provided sufficient detail to draft an appropriate work order. Per Entergy procedure
EN-HU-106, Procedure and Work Instruction Use and Adherence, Revision 3,
informational use procedures are not required to be in-hand during the performance
of a task. The NRC team noted that one of the CAPR-1 options revised EN-FAP-
WM-011 and the other created a site specific procedure that mirrors the subject
requirements of EN-FAP-WM-011.
The NRC team could not reconcile how revising an already adequate informational
use procedure, which was not understood, or creating a new site-specific procedure
that mirrors the requirements of EN-FAP-WM-011, which was also going to be
informational use, based on interviews, would ensure that planning personnel
would always know and understand work order planning standards. Additionally, the
NRC team noted that Entergys planned corrective actions did not ensure that new
planners would be aware of the operating experience associated with this event and
did not revise any initial or create any planner refresher training requirements, which
could reasonably result in repetition of the issue.
As a result of the NRC teams questions, Entergy stated that they planned to make
the planning standard checklist of CAPR-1 continuous use, to ensure that planners
will always have the checklist in hand when planning work to ensure that appropriate
vendor technical information is always included in applicable work instructions. On
January 26, 2017, continuous use procedure 1.13.2, Vendor and Technical
Information Reviews, Revision 0, became effective to address CAPR-1 of the CR-
PNP-2016-06635 root cause evaluation. Entergy entered the NRC teams concerns
in the corrective action program as CR-PNP-2017-00687 and CR-PNP-2017-00936.
Analysis. The NRC team determined that Entergys failure to develop appropriate
CAPRs in accordance with procedure EN-LI-102, was a performance deficiency.
equipment performance attribute of the Initiating Events cornerstone and if left
uncorrected, the performance deficiency would have the potential to lead to a more
Enclosure
64
significant safety concern. Specifically, if left uncorrected, the performance

deficiency could have the potential to result in repetition of a significant condition
adverse to quality, loss of control of feedwater regulating valve 642A and a manual
scram, or a similar significant condition adverse to quality. The NRC team evaluated
the finding using Exhibit 1, Initiating Events Screening Questions, of IMC 0609,
Appendix A, Significance Determination Process for Findings At-Power, and
determined this finding did not cause a reactor trip or the loss of mitigation
equipment relied upon to transition the plant from the onset of a trip to a stable
shutdown condition. Therefore, the NRC team determined the finding was of very
low safety significance (Green). The NRC team determined that the finding had a
cross-cutting aspect in the area of Human Performance, Procedure Adherence,
because individuals did not follow processes, procedures, and work instructions.
Specifically, Entergy did not follow procedure EN-LI-102, which provides the station
standards for crafting a corrective action and states, in part, that the corrective action
addressed [H.8].
Enforcement. Entergy failed to develop appropriate CAPRs for a significant

condition adverse to quality in accordance with EN-LI-102, Corrective Action
Process, Revision 20. The NRC team did not identify a violation of regulatory
requirements associated with this finding since the feedwater system is not a safety-
related system. The issue was entered into Entergys corrective action program as
CR-PNP-2017-00687 and CR-PNP-2017-00936. Because this finding does not
involve a violation and is of very low safety or security significance (Green), it is
identified as a finding. (FIN 05000293/2016011-03, Failure to Issue Appropriate
Corrective Actions to Preclude Repetition for the Causes of the September
2016 Scram)
5.4 Work Order Backlog Review for Significant Conditions Adverse to Quality and
Conditions Adverse to Quality
The NRC team performed a sample review of items contained in the work order
system to verify that items were properly prioritized and conditions adverse to quality
were corrected appropriately. PNPS had implemented corrective actions associated
with the 95003 Recovery Plan to specifically address the work order backlog. These
actions included trending historical open work orders against a threshold for
acceptability and reassigning resources to other departments, as needed, to perform
the necessary work.
PNPSs work order process was assessed against Entergy procedure EN-WM-100,
Work Request Generation, Screening, and Classification. The NRC team reviewed
CRs that identified incorrect prioritization of work orders identified as a result of the
95003 recovery actions and observed the conduct of work order prioritization
meetings. Through the review of documentation, the NRC team did not identify any
work orders that were incorrectly prioritized or characterized for significant conditions
adverse to quality or conditions adverse to quality. Overall, the NRC team
Enclosure
65
determined that the station was taking appropriate actions, in accordance with the IP
95003 Recovery Plan, to reduce the work order backlog.
5.5 Implementation of the Trending and Performance Review Process
In the Corrective Action Program Fundamental Problem root cause evaluation, the
trending program for adverse conditions was identified through the extent of
condition review as an area that required improvement. Entergys planned actions to
address this area included use of a subject matter expert, on an interim and, to a
lesser extent, long-term basis to provide training, coaching/mentoring, and oversight
of the trending program. In addition, training was provided on various topics to the
department improvement coordinators and department managers and supervisors
who participated on the Performance Improvement Review Group. The Entergy
trending and performance review process procedure was revised to enhance staff
guidance.
The NRC team reviewed Entergys process for trending within the corrective action
program to ensure that potential negative changes in performance were identified,
evaluated, and corrected to prevent future problems. The NRC team reviewed
documents, attended meetings, and conducted interviews with personnel who
implement the program.
Overall, the NRC team noted that the station had shown improvement at identifying
trends, including use of trend codes for CRs, and following the Entergy fleet
procedure to evaluate and resolve those trends. The additional training and support
from the subject matter expert had enhanced the department performance
improvement coordinators understanding of the process, how to collate data, and
how to assess that data.
The NRC team identified performance gaps in the resolution of adverse trends or
planned improvement actions. During review of the stations Aggregate Performance
Review Meeting and Departmental Performance Review Meeting documentation,
multiple examples were identified where improvement items were considered closed
or resolved before all applicable actions had been completed. Per the fleet
procedure, an item cannot be considered resolved until the CR is closed and clearly
defined effectiveness measures, which focus on the underlying behaviors that led to
a negative trend, were satisfactorily completed. However, Entergy was not
implementing the effectiveness measures as described, and focused on the absence
of events rather than the underlying behaviors. The NRC team also found examples
of trends identified outside of an Aggregate Performance Review Meeting or
Departmental Performance Review Meeting (i.e., documented in a CR) that were not
Enclosure
66
included in these review meetings so that the trend could be tracked to resolution. In
these cases, corrective actions for the adverse trends or improvement items were
not necessarily implemented to fix the problem. Entergy documented these
observations in the corrective action program as CR-PNP-2017-00303, CR-PNP-
2017-00307, and CR-PNP-2017-00330. The NRC team did not identify any
examples where items for improvement were inappropriately considered closed that
resulted in an adverse impact. In addition, the NRC team did not identify any
examples where identified trends that were not subsequently reviewed in an
Aggregate Performance Review Meeting or Departmental Performance Review
Meeting resulted in an adverse impact. Therefore, the NRC team determined that
these program implementation deficiencies were minor.
No findings were identified
5.6 Corrective Action Program Implementation: Problem Identification
The NRC team performed walkdowns of various plant systems to verify that Entergy
was conducting appropriate system walkdowns, identifying issues with a low
threshold, and completing appropriate corrective actions.
5.6.2 NRC Inspection Findings and Observations
During the walkdowns, the NRC team identified multiple minor equipment issues that
were subsequently captured in the corrective action program. The NRC team
assessed the identified issues and determined, for the most part, that they did not
affect system performance or reliability. When issues were identified that could have
the potential to adversely affect a system, the NRC team noted that those CRs were
not always classified appropriately (for example, considered non-adverse conditions
when they were adverse), were not initiated in a timely manner, or were not assigned
operability/functionality assessments as required. As each specific example arose,
those issues were discussed with Entergy and appropriate actions were taken.
Specific concerns related to operability/functionality assessments are described in
Section 6.3 of this report. These walkdowns illustrated the continued need for station
improvement at identifying and entering items into the corrective action program and
ensuring that issues are classified appropriately to support timely and effective
decision-making and action.
No findings were identified
5.7 Implementation of the Corrective Action Program during Recovery Evaluations
The NRC team reviewed documents and reports generated for the IP 95003
recovery plan development and implementation. Through PNPSs recovery
Enclosure
67
evaluations, the station identified 773 negative observations and 177 standards
performance deficiencies. The NRC team reviewed a sample of these negative
observations and standards performance deficiencies to verify that they were
included in the corrective action program appropriately and that identified issues
were corrected in accordance with their safety significance.
The negative observations and standards performance deficiencies were then

systematically evaluated by the PNPS Recovery Team to identify the overall
fundamental problems and problem areas. Most of the negative observations and
standards performance deficiencies were closed to corrective actions contained
within the respective root and apparent cause evaluations for the different areas. In
these cases, the NRC team verified whether the corrective actions adequately
addressed the conditions described in the negative observations and standards
performance deficiencies.
Overall, the NRC team determined that Entergy, using appropriate fleet procedures
and guidance, systematically assessed conditions identified in the corrective action
program to evaluate larger station performance issues in the formation of their
fundamental problems and problem areas and corrective actions to address those
performance issues.
Each section within this report discusses the individual fundamental problem and
problem area evaluations conducted after the collective evaluation report was
constructed. Issues identified during those specific reviews are discussed in their
respective sections.
5.8 Corrective Action Program Staffing and Training Adequacy
The NRC team reviewed the stations staffing and training adequacy as they related
to the implementation of the corrective action program. Entergy identified in the
Corrective Action Program Fundamental Problem root cause evaluation report that
inadequate training and a lack of resources were both contributing causes to the
decline in standards and performance of the station in the area of corrective action
program. Specifically, Contributing Cause 2 states, PNPS personnel who initiate,
disposition, and approve corrective action program products have not received
adequate training commensurate with their corrective action program roles and
responsibilities. This has resulted in unacceptable quality of some products.
Contributing Cause 3 states, PNPS leadership has not effectively managed the
resources to implement and sustain the corrective action program. This resulted in
declining corrective action program performance for the identification, evaluation and
resolution of station issues.
Enclosure
68
Corrective actions from the corrective action program root cause evaluation were
generated to address these areas. Training corrective actions focused on the
initiation and closure of CRs for all site personnel; trending, CR classification, and
closure requirements for the department improvement coordinators; and CR initiation
and closure requirements for supervisors and above. In the area of resources, the
site hired contractors to perform all cause evaluations (site personnel had their
qualifications removed because of the insufficient products that were being
generated based on inadequate training); brought in subject matter experts to
provide oversight of corrective action program meetings, focusing on leadership
behaviors, and reviews of all corrective action program products; and hired mentors
to work with the station staff on improving the trending, operating experience, and
self-assessment programs. Entergy also split the Performance Improvement group
into one set of people specifically focused on core corrective action program
responsibilities and one set of people focused on the other areas such as trending
and operating experience. New qualification cards were generated for the
department performance improvement coordinators to better define their roles and to
adequately train them on their duties within the corrective action program.
Through interviews and document reviews, the NRC team reviewed Entergys
corrective actions and assessed if they were adequate to address the issues
identified in the root cause evaluation report. Interviews with plant personnel who
implement the corrective action program illustrated that training and resources were
definitely lacking and sometimes inhibited proper performance of corrective action
program responsibilities prior to the recovery efforts. The interviews also revealed
that the new training and the department performance improvement coordinator
qualification standard were helpful in realigning the station on the standards and
expectations of the corrective action program and what each individual was
responsible for within that program. The department performance improvement
coordinators especially seemed to gain knowledge, clarification, and detail that was
previously lacking. The NRC team noted this training was effective in the higher
quality products generated and discussions held during the various corrective action
program-related meetings.
The NRC team noted that most of the corrective actions associated with resources
focused on hiring external personnel to fill in the gaps where the sites performance
was inadequate. The NRC team noted that without all of the supplemental
personnel, PNPS did not appear to have adequate resources to handle the work load
in the corrective action program. For example, related to the performance of causal
evaluations, PNPS would not have trained or qualified personnel to perform those
duties if the supplemental resources left the station. In other cases, such as with the
department performance improvement coordinators, some personnel with corrective
action program responsibilities also have other duties to fulfill within the stations
organization. While these actions were determined to be appropriate for interim
measures, the NRC team discussed with PNPS the need to emphasize behavioral
changes to ensure sustainability of improvements in areas where the site personnel
were relying on subject matter experts or mentors to prevent errors from occurring.
The NRC team also noted that corrective action program activities will continue to
require strong support by Entergy to sustain improvements in this area.
Enclosure
69
5.9 Self-Assessment and Benchmarking Activities
Through the Collective Evaluation process, Entergy identified that while no single
event or action appears to have triggered their performance decline, a gradual
decline of performance began at least five years ago but was not recognized in its
early stages due to inadequate self-assessments.
Ineffective Performance Improvement Activities
Entergy performed a Comparative Assessment Review to determine whether

weaknesses, similar to those identified during the ANO IP 95003 Recovery process,
were present at PNPS. Similar to the ANO Corrective Action Program Fundamental
Problem, and Performance Tools Problem Area, PNPS identified that implementation
of performance improvement activities had not been effective. As a result, problems
were left uncorrected until identified by external groups or self-revealing events
occurred. Entergy identified that the performance improvement tools that were not
used effectively included:

Self-Assessments
Benchmarking
Performance Assessment
Operating Experience
Observations
The PNPS Recovery Team concluded during the Collective Evaluation process that
the ineffective use of performance improvement tools was one of the problems
indicative of a fundamental problem in the corrective action program, and that it
would be further evaluated and addressed in CR-PNP-2016-00716, Implementation
of the Corrective Action Program 95003 Root Cause Evaluation.
Entergy documented the following in the corrective action program root cause
evaluation report:
Contributing Cause 1 stated, in part, that PNPS personnelresponsible for

performance monitoring and oversight failed to provide adequate assessment
of corrective action program performance. This contributed to leadership not
recognizing the need for additional action to mitigate the corrective action
program performance decline. The lack of self-critical assessments
contributed to multiple problems that were either self-revealing or identified by
external departments and agencies. The assessment process was not used
by station leadership to self-identify the corrective action program
implementation weaknesses in the early stages of decline.
Enclosure
70
As a result of Entergys extent of condition review, the object of the corrective action
program root cause evaluation was expanded to include Trending, Operating
Experience, Self-Assessments and Benchmarking.
Entergy identified the following key corrective actions to address ineffective

performance improvement activities:
Require department performance improvement coordinators to review closed

corrective actions for quality for priority level 1 and level 2 corrective actions
and 50 percent of level 3 corrective actions. The intent of this action is to
ensure station CR corrective action priorities 1 thru 3 actions are closed in
accordance with corrective action program procedures and to provide
feedback to individuals to improve closure quality.
Develop and implement a performance scorecard for Condition Review

Group, Corrective Action Review Board, and Self-Assessment Review Board
meetings. This scorecard is to include ratings for leadership accountability,
behaviors, and results expected during these meetings. The intent of this
action is to improve Condition Review Group, Corrective Action Review
Board, and Self-Assessment Review Board effectiveness by rating and
trending performance results.
The Entergy Corrective Action Program/Operating Experience Corporate

Functional Area Manager is to evaluate the Entergy Corrective Action
Program Excellence Plan (LO-HQNLO-2015-00073) and revise as
necessary to ensure the plan incorporates the CR-PNP-2016-00716 root
cause evaluation conditions and appropriate fleet corrective actions to
address the identified corrective action program and problem identification
and resolution program weaknesses (i.e. Identify, Evaluate, and Correct;
Operational Experience; Trending; and Self-Assessments and
Benchmarking).
Assign a subject matter expert to coach and mentor personnel who

implement the operating experience, trending, self-assessment, and
benchmarking processes. The intent of this action is to provide data that
supports the oversight provided by CAPR-1 for sustained improved
performance.
Ineffective Corporate Oversight
The PNPS Recovery Team also concluded, during the Comparative Assessment
Review, that similar to the ANO Corporate and Independent Oversight Fundamental
Problem (i.e., NIOS), corporate organizations have not consistently monitored and
evaluated PNPS performance to ensure performance gaps are identified and
corrected in a timely manner. Corporate oversight did not routinely monitor station
performance information through diverse means, such as personal observations and
independent and line management oversight. As a result, the station had not always
been effective in conducting timely and effective independent self-assessments,
assuring that performance gaps are resolved, and that line management takes timely
action to correct issues. Additionally, the corporate NIOS organization did not
Enclosure
71
consistently provide senior leaders with objective assessments of how site

performance compares to the industry. This resulted in inadequate communication
of issues to line management, lack of independence between NIOS personnel and
the line organizations, and inconsistency with identifying substantial performance
shortfalls.
The PNPS Recovery Team subsequently concluded that the issue of inconsistent
corporate oversight was one of the problems indicative of a Nuclear Safety Culture
(Leadership, Resources, and Oversight) Fundamental Problem, and that it would be
further evaluated and addressed in CR-PNP-2016-02052, Nuclear Safety Culture
95003 Root Cause Evaluation.
Entergys nuclear safety culture root cause evaluation report documented the
following:
Contributing Cause 1: Corporate leaders and independent oversight

organizations did not provide sufficient oversight of station performance to
ensure timely resolution of emerging, repetitive and long-standing
performance problems. This contributed to performance gaps not being
resolved by the station.
Entergy identified the following key corrective actions in CR-PNP-2016-02052 to

address ineffective corporate oversight:
Perform benchmarking (by a current Management Review Meeting member)

at an industry leading station on Operational Excellence Management Review
Meeting content, leadership behaviors exhibited and execution of an
Operational Excellence Management Review Meeting. The results will be
contained in a benchmark report and documented along with action items in
the corrective action program. The lessons-learned will be communicated to
the members of the PNPS Operational Excellence Management Review
Meeting. The intent of this corrective action is to determine what good looks
like when it comes to Operational Excellence Management Review Meeting
content, behaviors and execution and allow for needed improvements.
Ensure the Entergy Nuclear Sustainability Plan addresses the issues

documented in the root cause evaluation relating to corporate oversight and
NIOS.
Revise EN-FAP-OM-011, Corporate Oversight Model, to include:
o Station nuclear safety culture output from the Nuclear Safety Culture
Monitoring Panel and the associated performance indicators as inputs to
the Oversight Analysis Meeting and Oversight Review Board.
o Once per trimester (approximately three times per year), leaders from the
Operations Support, Engineering, Nuclear Oversight, and Licensing
departments will hold an Oversight Analysis Meeting to evaluate plant
performance and discuss any changes in plant categorization that should
Enclosure
72
be recommended to the corporate senior leadership team. The meeting

will be chaired by a Vice President of Operations Support.
Revise EN-FAP-OM-002, Management Review Meetings, to prioritize

review of nuclear safety culture status and regulatory performance to the
Operational Excellence Management Review Meeting agenda.
The NRC team reviewed a sample of, and processes for, audits and assessments
conducted by the PNPS line organization, Entergy corporate, and both onsite and
corporate NIOS organizations to evaluate program effectiveness and assess the
appropriateness of station response. Specifically, the NRC team reviewed Entergy
procedures EN-LI-104, Assessments and Benchmarking, EN-FAP-OM-011,
Corporate Oversight Model, EN-LI-128, Mid-Cycle Assessment Process, and EN-
QV-109, Audit Process, and reviewed a sample of historical and recent focused
self-assessments, snapshot assessments, corporate mid-cycle assessments, onsite
NIOS audits, and a corporate NIOS self-assessment of the Entergy Northern Fleet.
The NRC team also interviewed station management, staff, and subject matter
experts/mentors responsible for coaching and mentoring personnel who implement
the self-assessment process. The NRC team reviewed a sampling of CRs, learning
organization documents, NIOS findings, and Elevation/Escalation letters generated
as a result of internal self-assessment/audit reports to assess the appropriateness
and timeliness of the station managements support and response.
The NRC team also evaluated PNPSs recovery efforts to address the weaknesses
identified in the areas of internal self-assessments, as documented in fundamental
problem root cause evaluations CR-PNP-2016-00716, Implementation of the
Corrective Action Program, and CR-PNP-2016-02052, Nuclear Safety Culture.
See Sections 5.1 and 7.1 of this report, respectively, for a more detailed assessment
of these fundamental problems.
Finally, the NRC team reviewed external assessments of PNPS to ensure that NRC
perspectives of Entergy performance were consistent with any issues identified
during these assessments. The NRC team also reviewed these reports to determine
whether any significant safety issues were identified that required further NRC follow-
up.
Internal Self-Assessments
The NRC inspection team evaluated the progress of Entergys efforts to address the
weaknesses identified in the area of internal self-assessments and concluded that
Entergys evaluation and characterization of the performance issues in the area of
internal self-assessments were appropriate. The NRC team found that the
population of internal self-assessments/audits reviewed were performed in
accordance with the appropriate Entergy procedures, were generally self-critical, and
appeared to be an effective means for PNPS to identify and assess performance
issues. Particularly, the NRC team noted that the quality of the more
recently-conducted assessments was generally higher, indicating ongoing
Enclosure
73
improvement in this area. The population of CR and learning organization

documents reviewed were also appropriately resolved in a manner commensurate
with their safety-significance, or had due dates that were reasonable.
Station Responsiveness to NIOS-Identified Issues
Regarding the NRC teams assessment of the responsiveness of station

management to issues identified by the onsite NIOS group, through interviews, the
NRC team concluded that, overall, the stations responsiveness/priority given to
NIOS-identified issues has improved in the last couple of years and was generally
viewed as adequate and on an improving trend. This recent improving trend was
viewed to be largely driven by the reported improved relations between the NIOS
manager and the Site Vice President and General Manager of Plant Operations.
Although the level of responsiveness received from the station on NIOS-identified

issues was considered to be improving, interview results and NRC team
observations reflected that the pace at which those issues were being resolved was
not always consistent with the significance of the identified issue. For example, in
May 2016, NIOS issued an elevation letter (CR-PNP-2016-03090) to the General
Manager of Plant Operations regarding poor performance in Work Management due
to the fact that important station work had continued to incur delays and was
frequently unable to start as scheduled, or work groups encountered problems that
delayed completion of work. Although short term improvements were noted following
the issuance of that elevation letter, performance in Work Management proceeded to
degrade once more, necessitating the issuance of an NIOS Escalation Letter (CR-
PNP-2016-08099) to the Site Vice President in October 2016. The NRC team
concluded that the persistence of this NIOS issue and the untimeliness of its overall
resolution, illustrated that responsiveness given to NIOS-identified issues by station
management required improvement. As of the time of this inspection, corrective
actions to resolve this issue were still in progress.
External Assessments
The NRC team did not identify any additional safety-significant issues in PNPSs
external assessments that required additional inspection follow-up.
5.10 Use of Industry Information
Entergy did not identify that a significant contributor to performance problems at

PNPS were deficiencies in the evaluation and use of operating experience.
However, root cause evaluation CR-PNP-2016-00716 (Corrective Action Program
Fundamental Problem) evaluated weaknesses in the implementation of the
corrective action program, as well as conditions adverse to quality and significant
conditions adverse to quality that are recurring and longstanding. As a part of the
Enclosure
74
CR-PNP-2016-00716 extent of cause evaluation, the station reviewed performance

improvement programs including operating experience, trending, self-assessments,
and benchmarking.
The CR-PNP-2016-00716 root cause evaluation described examples of weaknesses

with the stations use of operating experience, including:
A Standards Performance Deficiency (CR-PNP-2015-05829) regarding

significant quality issues with identification and use of internal and external
operating experience in Corrective Action Review Board-approved apparent
cause evaluations at PNPS
Corrective Action Audit, QA-3-2015-PNP-1 (CR-PNP-2015-04731), which

concluded, The Operating Experience Program is unsatisfactory due to
backlog of untimely reviews and acknowledgements of [category B1
operating experience]. This is a systemic problem across the site.
Insights from the Standards Performance Deficiency assessment, which

noted that some root and apparent cause evaluations did not use operating
experience to help identify the causes which could leave PNPS more
vulnerable to repeat events of the same or similar nature.
CR-PNP-2016-01314, Operating experience review was not used to aid in

developing the specific root and contributing causes. PNPS closed this CR
to CR-PNP-2016-00716 and considered this condition during performance of
this root cause evaluation.
The NRC team reviewed Entergy procedure EN-OE-100, Operating Experience

Program, Revision 26, interviewed PNPS operating experience staff members, and
conducted plant walkdowns. The NRC team reviewed a sample of operating
experience evaluations, as well as PNPSs use and consideration of applicable
operating experience in recent cause evaluations.
Based on the samples selected for review, the NRC team determined Entergy
generally implemented procedure EN-OE-100 adequately as it relates to sharing,
screening, evaluating, implementing actions, and oversight for fleet and industry
operating experience. However, the NRC team identified examples of issues with
the implementation of the operating experience program. Specifically:
The NRC team identified four operating experience records that were not
screened as B1 in accordance with Section 5.4 of EN-OE-100, Revision 26.
The NRC team determined these issues to be of minor significance since the
failure to adequately screen these operating experience records had no
consequence, and the NRC teams concerns were entered into the corrective
action program by Entergy as CR-HQN-2017-00049.
Enclosure
75
The NRC team identified that although the condition analysis for the recent
A emergency diesel generator radiator cooling fan gearbox event (CR-PNP-
2016-07743) included a review of internal and external operating experience,
the review did not identify an external operating experience item related to a
similar North Anna emergency diesel generator issue that occurred in
September 2013. The NRC team later determined that Revision 23 of EN-LI-
118, Cause Evaluation Process, effective October 11, 2016, no longer
requires an operating experience review for this level of cause evaluation.
PNPS entered the NRC teams observation into the corrective action program
as CR-PNP-2017-00935.
5.11 Comprehensive Recovery Plan Metrics
The NRC team developed an understanding of each individual metric and reviewed
the performance of each metric since it was implemented and considered a recovery
plan metric. The NRC team reviewed procedures related to the metric parameters
being monitored, interviewed the metric and action plan owners, and assessed
whether the metric could monitor for improved performance.
The NRC team identified no concerns with the metrics being monitored by Entergy.
The NRC team determined that Entergy had effectively identified existing metrics
that would enable them to monitor for improving performance. The NRC team
determined that Entergy had established some leading indicators in an attempt to
flag declining performance earlier, particularly related to a safety conscious work
environment. The NRC team challenged Entergy as to why they believed using
existing metrics would demonstrate improved performance. Entergy replied that the
increased cooperation among managers and challenges among managers resulted
in increased focus on monitoring the direction of the metrics being monitored. The
NRC team determined that Entergy initiated corrective documents monthly for any
metric identified as red. Entergy implemented this to ensure that they captured poor
performance in their corrective action program. The NRC team determined that the
level of detail being included with the metrics and the associated graphs continued to
improve and provide for better assessment and planned corrective actions. Many of
these improvements resulted from assessment comments provided by the quality
assurance organization.
The NRC team determined that the increased focus on improving the items being
assessed, the revised attitude towards improved performance, and the increased
challenges among the managers created an atmosphere that should improve site
performance. The NRC team identified no issues with the metrics being used to
measure improved performance.
Enclosure
76
6. Reactor Safety Strategic Performance Area
Human Performance Key Attribute (IP 95003, Section 02.03c)
6.1. Decision-Making and Risk-Recognition Fundamental Problem Area
PNPS determined that a fundamental problem existed in the area of decision-making

and risk-recognition. Specifically, Entergy performed evaluations as part of the NRC
IP 95003 preparation and identified that in some cases, risk-significant decisions were
made by station leaders without recognizing and managing risk. Flawed risk-
significant decisions had negatively impacted work processes, equipment reliability,
and resulted in station events.
Entergys decision-making and risk-recognition root cause evaluation (CR-PNP-

2016-02054) documented that station procedures were inadequate to address
planned maintenance on offsite transmission equipment, which led to a plant event;
the station was found to not always apply a conservative bias when making
decisions; longstanding weaknesses in the stations implementation of the preventive
maintenance program indicated a lack of recognition of the risk; and, decision-
making had been adversely impacted by flawed assumptions that resulted in risk
being inappropriately accepted by individuals or the organization.
Entergy documented the following in the root cause evaluation report:
Root Cause 1: Station leadership has not consistently exhibited behaviors

that set the requisite standards and expectations for consequence-biased
decision-making and effective operational risk management, consistent with a
strong nuclear safety culture.
Contributing Cause 1: Station leadership skills and knowledge are

inadequate regarding the performance of operational risk assessments and
associated decision-making.
Contributing Cause 2: An effective risk assessment process has not been

fully established for identifying and managing operational risks in a
systematic, rigorous, and thorough manner, commensurate with a strong
nuclear safety culture.
Contributing Cause 3: Station leadership lacks a strong commitment to the

corrective action and operating experience programs for the prevention of
risk-significant station events.
Contributing Cause 4: Station leadership has demonstrated insensitivity to

regulatory risk.
Enclosure
77
Contributing Cause 5: Entergy nuclear independent oversight organizations

(i.e., NIOS and the Safety Review Committee) have not consistently
performed timely and effective assessments, monitoring, and evaluation of
station performance relative to risk-significant decision-making.
Entergy documented the following key corrective actions in the decision-making and
risk-recognition root cause evaluation:
CR-PNP-2016-02054 CA-24: (CAPR-1) Establish and institutionalize

expectations and accompanying accountability for station leadership (i.e.,
supervisors and above) regarding consequence-biased decision-making and
effective risk management. Incorporate these expectations formally into the
continuous performance monitoring and feedback process in accordance with
EN-FAP-OM-016, Performance Management Processes and Practices, for
station leadership (i.e., supervisors and above), with attendant accountability
to change and shape behaviors, reinforce expectations and standards, and
achieve the desired results.
CR-PNP-2016-02054 CA-26: Augment the station staff with an external

subject matter expert in the area of risk assessment as a full-time position to
mentor and assess individual leadership behaviors and performance against
the established leadership expectations. Perform observations of leadership
performance against the established leadership expectations and provide
feedback to that leaders Manager or Director.
CR-PNP-2016-02054 CAs-36, 37: Conduct leadership training to reinforce

the established station leadership expectations, specific principles related to
Teamwork and for Integrated Risk Management and Decision-Making.
CR-PNP-2016-02054 CA-38: Revise governing risk assessment procedures

to include guidance in line with current industry standards.
The NRC team reviewed the decision-making and risk-recognition root cause
evaluation, CR-PNP-2016-02054, and supporting documents to assess: 1) whether
the identification of risk-recognition and decision-making as a fundamental problem
was appropriate; 2) whether the identified root and contributing causes were
appropriate; 3) whether the corrective actions identified to address the root and
contributing causes were appropriate; 4) whether the corrective actions that have
been implemented were adequately implemented; 5) whether identified EFRs
adequately assess the effectiveness of the corrective actions; 6) whether the
implemented EFRs were adequately performed; and 7) through independent
performance-based inspection, whether the overall problem was effectively
addressed. Specific decision-making meetings observed by the NRC team during
this review included:
Critical Evolution Meetings;

Plant Health Committee/Critical Decision Meeting;
Leadership & Alignment Meetings;
Enclosure
78
Critical Decision Meetings; and

T-2 Technical Rigor Risk Review Meetings.
The NRC team also performed detailed assessments of the key corrective actions to
evaluate whether they were developed appropriately to achieve their stated
objectives. Through interviews, independent observations of station leaders in
decision-making meetings, and document reviews, the NRC team evaluated if the
corrective actions were being implemented as intended.
Establish and Institutionalize Expectations/Accountability (CAPR-1)
The NRC team reviewed and assessed implementation of CR-PNP-2016-02054 CA-

24 (CAPR-1). Specifically, the NRC team:
Assessed whether the new concepts were being demonstrated by station

leaders
Assessed whether risk assessment tools used to support decision-making

were clear, understandable, and adequate
Reviewed implementation of PNPS procedure 1.3.142, PNPS Risk Review

and Disposition, through a sampling of completed or in-progress risk reviews
Augmentation of Station Staff with Subject Matter Experts
The NRC team reviewed and assessed implementation of CR-PNP-2016-02054

CA-26. Specifically, the NRC team:
Evaluated qualifications of subject matter experts through review of

biographical information, resumes, work history, and interviews
Observed subject matter experts in action, such as during decision-making

meetings, to observe typical interactions with station management and
personnel
Reviewed assessment reports, CRs, and other pertinent written products

generated by the subject matter experts to assess their effectiveness in
improving plant performance
In addition to the decision-making/risk-recognition root cause evaluation, the NRC

team also reviewed the following areas:
Long-Standing Equipment Issues
The NRC team reviewed and assessed decision-making regarding long-standing

equipment issues. Particularly, for any unresolved long-term equipment issues (with
a focus on degraded or non-conforming conditions of safety-related structures,
systems, or components greater than one year old), the NRC team determined
whether inadequate resources were a cause, or contributed to any inappropriate
delay in resolving those issues.
Enclosure
79
In preparation for the IP 95003 inspection, PNPS performed an Allocation of

Resources Performance Area Report, which was reviewed by the NRC team to
assess whether Entergy corporate and PNPS had appropriately allocated resources
for modifications and other important work activities to ensure consideration was
given to safety (risk) and compliance with regulatory requirements. Further, the NRC
team assessed whether Entergy had appropriately identified issues within this causal
area and planned or implemented appropriate corrective actions.
Within this assessment, backlogs associated with modifications and other important
work were assessed to determine whether resources were provided to ensure
manageable workloads and prevent the need for workarounds (including operator
workarounds) that could increase the likelihood of an initiating event or complicate
accident mitigation.
The NRC teams conclusions were in line with PNPSs Allocation of Resources
Performance Area Report. The following is excerpted from this report:
Significant weaknesses were identified in all four objective areas

[Operations, Engineering, Maintenance, and the Site-wide
miscellaneous objective area, which includes such areas as
Corrective Action Program, post-maintenance testing, unplanned
limiting condition for operation entries, etc.]. Site backlog issues were
seen in areas such as the level of capital spending, low staffing levels
and issues with the corrective action program. Operations backlog
issues were seen in operators acceptance of longstanding issues.
Engineering issues were seen in backlogs, [preventive maintenance]
and acceptance of longstanding issues. Maintenance backlog issues
were seen with the high backlog levels associated with maintenance
items such as [preventive maintenance], work orders and leak repairs.
In all areas, acceptance of risk and in some cases a lack of
awareness of risk were identified.
The following excerpts from the Allocation of Resources Performance Area Report
illustrate some of the specific observations Entergy identified during their
assessment:
The staffing level at PNPS was significantly below the average of other small
boiling water reactors. The manning levels appear to be leading to an
increase in backlogs.
The staffing at PNPS from 2006 to 2014 had lowered by over 115 full-time
equivalents as compared to the average small [boiling water reactor] staffing.
The deviation is over 50 [full-time equivalents] when comparing to the
median. (This data is based on Electric Utility Cost Group information.) As a
consequence, the staffing levels appear to be leading to an increase in
backlogs.
[Fix-it-Now] team resources were inadequate to meet their objective to control

the maintenance backlog. As a consequence, maintenance backlogs were
growing larger and older.
Enclosure
80
Work week manager staffing was at two [employees]. The normal staffing for
this position is four.
The magnitude of some backlogs in Maintenance, Work Planning,

Engineering, Corrective Action and Operations are inconsistent with industry
or fleet standard performance levels. The high backlogs pose increased risk
to the site and reduce the ability to effectively understand and manage risk.
Several safety and reliability-related plant or program upgrades had been

deferred through several operating cycles. This deferral of work had
increased the risk to the site.
Risk reviews were not found or were weakly documented for some important
backlogs and work deferrals. This led to a lack of understanding of the risk
and potentially to the improper prioritization of work.
In some cases, the PNPS team does not understand the funding process fully
or for other reasons does not take the appropriate action to obtain funding for
plant issues in a timely manner. As a consequence, resolution of issues have
been delayed.
CR-PNP-2014-01990 was written by NIOS due to multiple electrical

calculations that exceeded the procedural direction for updating. Discussions
with engineering personnel indicate that this backlog was due in part to the
[Human Capital Management process].
The performance improvement department was unable to provide the needed

oversight of corrective action management, causal analysis quality, and
trending.
Additionally, in preparation for the IP 95003 inspection, Entergy performed an

assessment to compare the recent IP 95003 issues of ANO for possible applicability
to PNPS. This third-party Comparative Assessment Review concluded that ANOs
Organizational Capacity Problem Area (i.e., resources) was applicable to PNPS, as
documented in CR-PNP-2016-01465. Specifically, the Comparative Assessment
Review stated:
Review of historical data at [PNPS] suggests staffing and resources

for each department or functional area needed to support their
assigned responsibilities as well as to facilitate cross-functional
responsibilities has not been consistently provided. Consideration
and mitigation of the potential effects of organizational changes and
staff reductions has not always been performed before these are
initiated. As a result, the station has not always been effective with
providing consistent support of the Work Management Process,
effective resolution and mitigation of problems that could challenge
safe plant operation, and managing collective dose (as examples).
The NRC team noted that Entergy did not classify resources as a stand-alone
problem area in the Comprehensive Recovery Plan, but instead chose to address
Enclosure
81
the issue of resources by incorporation into the overarching Safety Culture

Fundamental Problem, and addressed this area through the corrective actions
associated with root cause evaluation CR-PNP-2016-02052. See Section 7.1 of this
inspection report for the NRC teams assessment of this causal factor and
associated corrective actions.
Comparison to ANO IP 95003 Issues
The NRC team reviewed the ANO IP 95003 inspection report and Comparative
Assessment Review to determine whether the issues that were identified at ANO
regarding decision-making/risk-management existed at PNPS, if they had been
identified by Entergy, and whether appropriate corrective actions had been
developed and implemented. Additionally, the NRC team determined whether the
corrective actions implemented at ANO were also identified for implementation at
PNPS, and if not, whether a reasonable basis existed for not implementing similar
actions.
The NRC team concluded that Entergys identification of decision-making/

risk-recognition as a fundamental problem was appropriate. The NRC team further
concluded that the root and contributing causes were appropriately identified by
Entergy and that the corrective actions developed by the station appeared to be
appropriate to address the root and contributing causes.
The NRC teams evaluation of the adequacy of corrective actions that had been
implemented included (at the time of inspection) 56 of the 63 corrective actions from
the root cause evaluation that were complete. Of those corrective actions sampled,
the NRC team determined that in some cases, more rigorous and consistent
implementation was required. Examples are discussed below.
Establish and Institutionalize Expectations/Accountability (CAPR-1)
Through the review of Entergys implementation of CAPR-1, the NRC team

concluded that the new expectations regarding consequence-biased
decision-making and effective risk management, created as a result of CAPR-1,
were appropriately developed based on widely-accepted industry standards.
Entergys actions thus far in the area of CAPR-1 generally have had a positive
impact in the decision-making onsite, however the NRC team had the following
observations:
The NRC team observed that, for the most part, station senior leadership
appeared to be practicing and demonstrating the new expectations and
concepts developed through CAPR-1. However, some station leaders
(managers and first-line supervisors) from across multiple departments
appeared to be lagging in their demonstration of the new decision-making
principles and implementation of procedure 1.3.142, PNPS Risk Review and
Disposition, as described in the examples below:
o An engineering manager directed the extension of 57 outage preventive

maintenance activities on 4KV and 480V breakers (some of which were
Enclosure
82
critical, safety-related functions) without sufficient technical justification

and did not utilize procedure 1.3.142, as intended by CAPR-1 (Reference
CR-PNP-2016-07486). This issue was identified by the PNPS subject
matter experts.
o An engineering manager stated, during an interview with the NRC team,

that there was reluctance to remove an emergency diesel generator from
service to perform extent of condition inspections for fear of incurring
undesired system unavailability time from a maintenance rule metric
standpoint.
o A control room supervisor failed to identify and challenge an emergency

diesel generator relay testing workgroup on December 7, 2016, when
they incorrectly presented their activities as low-risk, instead of high-risk
due to the associated 24-hour technical specification limiting condition for
operation. Following questions by a member of the NRC team observing
the activity, the station realized the appropriate risk categorization and
deferred the job until the appropriate, procedurally required actions (e.g.,
Critical Evolution Meeting, etc.) could take place. The NRC team
determined this issue was minor because it only affected integrated risk,
an administrative process, and did not impact the risk assessment
required by 10 CFR 50.65(a)(4). Entergy documented this issue in the
corrective action program as CR-PNP-2016-09739 and CR-PNP-2016-
09740.
o An in-field instrumentation and controls supervisor failed to identify and

take issue with multiple procedure non-compliances performed in his
presence.
o An in-field instrumentation and controls supervisor disregarded a

technicians comment regarding the apparent need for a procedure
enhancement when difficulties were encountered during the execution of
that procedure.
The NRC teams observations above suggested that the new standards and the
1.3.142 process as delineated by CAPR-1 were not consistently demonstrated by
all levels of station leaders.
One of the key actions in CAPR-1 was to formally incorporate the

newly-developed expectations into the continuous performance monitoring
and feedback process in accordance with EN-FAP-OM-016, Performance
Management Processes and Practices, for station leadership, with attendant
accountability. One of the ways in which Entergy planned to do so was by
utilizing the progressive Performance Management Model, including the use
of Targeted Performance Improvement Plans and Performance Improvement
Plans as appropriate, to change and shape behaviors, reinforce expectations
and standards, and achieve the desired results. The NRC team determined
that the Targeted Performance Improvement Plans were inadequate. (See
Section 7.1 of this inspection report for a detailed discussion of this issue.)
Enclosure
83
Regarding the NRC teams evaluation of whether the risk-assessment tools

used to support decision-making are clear, understandable, and adequate,
the NRC team concluded, through a review of procedure 1.3.142, PNPS
Risk Review and Disposition, Revisions 5, 6, and a draft of Revision 7, that
the procedure appeared sufficient to achieve its intended objective, provided
it is initiated when entry criteria are met and implemented with sufficient rigor.
With each subsequent revision reviewed, procedure 1.3.142 included more
clarification and explanation in sections where practice had revealed a need
for clarity to make the procedure more easily understood. The NRC team
concluded that the reviews completed in accordance with the 1.3.142
procedure are adequate to increase station sensitivity to integrated risk and
conservative decision-making, as outlined in CAPR-1, provided it is used
appropriately.
Through a sampling of completed or in-progress reviews conducted by

Entergy in accordance with procedure 1.3.142, PNPS Risk Review and
Disposition, the NRC team noted that the stations implementation of the
procedure was generally adequate. The risk decisions/deferrals that the
station chose as a result of this process appeared to be prudent, though with
varying levels of rigor demonstrated in the technical justifications.
The NRC team noted that from October to December 2016, subject matter
expert observations/reports identified that Entergy was not initiating a risk
review per procedure 1.3.142 as intended, nor sufficiently implementing all of
the procedure requirements when used for important risk decisions. As an
example, the subject matter experts identified various inconsistencies in the
implementation of procedure 1.3.142, such as the stations decision to use a
less restrictive corporate outage deferral process for a number of outage
planning decisions. Additionally, at the time, staff interviews revealed the
belief that entry into/use of the procedure was largely voluntary and subject to
management discretion, which led to inconsistent use of the process. At that
time, however, procedure 1.3.142 had just undergone a major revision, and
staff/management training was still underway. The subject matter experts
assisted in the development of the training materials and job aids. Those
revisions were intended to assist the performers to better understand and
execute the various criteria located throughout the procedure. Following the
training and roll-out of the procedure revision, some improvements were
noted in the level of initiation, thoroughness, and overall quality of completion
of the reviews conducted in accordance with procedure 1.3.142; however,
continued failures to utilize this process and additional cases of insufficient
detail/basis in the packages prompted the need for another major procedure
revision, which at the time of this inspection had not been completed.
Entergy developed three EFRs in CR-PNP-2016-02054: EFR-1, an interim

review to ensure improving trends towards the success goals established in
EFR-2, which is the final EFR; and EFR-3, which was developed for the non-
CAPR corrective actions in the root cause evaluation. In accordance with
EFR-1, the first assessment was to be completed in October 2016.
Subsequent assessments were to be completed in the month following the
end of each subsequent quarter, until the final EFR was completed and
determined whether the corrective actions had been effective. However, the
Enclosure
84
NRC team identified that Entergy failed to perform the first assessment in
October 2016. Entergy entered the issue into their corrective action program
as CR-PNP-2016-09717 and retroactively performed the October EFR in
January 2017. This EFR noted that CAPR-1 (CR-PNP-2016-02054 CA-24)
was closed on October 13, 2016, which was two weeks after the EFR
assessment period. Therefore, because CAPR-1 was not yet fully
implemented, Entergy could not evaluate the effectiveness of the action, and
concluded that the EFR was indeterminate.
Augmentation of Station Staff with Subject Matter Experts
Through the review of Entergys implementation of CA-26, the NRC team concluded
that the decision-making/risk-recognition subject matter experts were technically
qualified to act in the capacity of subject matter experts in their areas. A sample of
CRs generated by the subject matter experts in this area were reviewed.
Additionally, a sampling of recent bi-weekly/monthly subject matter expert roll-up
reports were reviewed. The bi-weekly/monthly reports were of high quality and
contained critical and constructive critiques of PNPS leadership and staff behaviors
along with recommendations for improvement in the area of decision-making and
risk-recognition. The NRC team concluded that the subject matter experts appeared
to have a positive impact on the improvement/recovery efforts of the station.
The nature of the subject matter experts interactions with PNPS leaders was
observed to be one of a consultation/recommendation-based relationship, so the
subject matter experts had no direct decision-making or line management authority,
other than the ability to generate CRs. In the interactions observed by the NRC
team, the PNPS senior leaders were generally receptive to the feedback and took
actions to address those items. However, based on interviews and a review of
current open corrective action program items generated by the subject matter
experts, the NRC team noted resistance to the improvement recommendations of the
subject matter experts by some station managers. For example, in reference to CR-
PNP-2016-07486, subject matter experts identified that numerous outage preventive
maintenance activities were extended without sufficient technical justification and
without conducting a risk review in accordance with procedure 1.3.142, PNPS Risk
Review and Disposition. After challenging the engineering department on the lack
of sufficient justification, another corrective action program action item was created
for engineering to review and enhance the original justifications. This follow-up
action, however, was still not completed to the level of rigor or standards that the
subject matter expert believed to be necessary to be in alignment with station
procedures and CAPR-1, so the subject matter expert elevated the issue to senior
management to drive a satisfactory resolution. At the conclusion of the onsite weeks
of this inspection, the resolution of this issue was still in progress.
The NRC team noted that the subject matter experts had recently shifted their
approach to directly writing CRs for identified issues instead of their previous
approach of attempting to first influence the station staff to self-identify the issue, as
a more effective way of impacting changes in station behavior. Additionally, the NRC
team noted that, as of the end of this inspection, the decision-making/risk-recognition
subject matter experts were instructed by the Site Vice President to focus more
attention directly on mentoring and coaching the operations shift managers as an
additional means of improving operations department decisions and behaviors.
Enclosure
85
Long-Standing Equipment Issues
Regarding the NRC teams assessment of Entergys decision-making regarding long-

standing equipment issues, the station provided the NRC team with a list of all
degraded or non-conforming conditions greater than one year old, with the oldest
current open degraded or non-conforming condition identified in 2011. Through a
review of CRs, work order backlogs, and interviews, the NRC team determined that
none of the identified long-standing degraded or non-conforming conditions were
attributed to a lack of resources (funding or staffing) or an inappropriate decision
impacting resources. The topic of Entergys allocation of resources, in general, is
evaluated in Section 7.1 of this inspection report.
Comparison to ANO IP 95003 Issues
The NRC team concluded that Entergys Comparative Assessment Review

adequately identified the ANO IP 95003 issues that were applicable to PNPS.
Particularly, in the area of decision-making/risk-recognition, the station identified that
decision-making/risk-recognition was also a fundamental problem at PNPS. The
following excerpt from the ANO IP 95003 inspection report documents ANOs
deficiencies regarding the identification of appropriate causal factors associated with
risk-recognition problem that was also identified at PNPS:
The Decision Making and Risk Management root cause evaluation

focused on decision-making as the problem and risk management
issues as a consequence, resulting in having inadequate corrective
actions to address risk management and recognition. The NRC team
identified examples that indicated ANO failed to manage risk because
they failed to recognize conditions that required a risk assessment. In
response, ANO developed a series of corrective actions that appear
to address the symptoms, but no cause analysis was performed.
This operating experience from ANOs IP 95003 inspection was appropriately

incorporated at PNPS. Additionally, the NRC team concluded that Entergy provided
sufficient justification to explain why some of the ANO issues did not apply or differed
from PNPS, and that the corrective actions developed by Entergy in this area were
appropriate.
6.2 Procedure Use and Adherence Problem Area
Entergy determined that procedure use and adherence was a problem area and
initiated CR-PNP-2016-02059 to determine an apparent cause and establish
corrective actions to resolve those causes. Entergy classified the CR as a Category
B and performed an apparent cause evaluation. The following is excerpted from
Entergys apparent cause evaluation:
Enclosure
86
Direct Cause: Station personnel do not consistently ensure that all applicable
requirements of Informational Use procedures are identified and followed.
Apparent Cause: Senior management had not effectively set the expectation
that guidance contained in Informational Use procedures will be identified
and implemented.
Contributing Cause 1: Supervisors do not reinforce the standard that

guidance contained in Informational Use procedures is identified and
implemented.
Contributing Cause 2: Performance monitoring and trending were not being

effectively used to identify behaviors of not following Informational Use
procedures.
Contributing Cause 3: The work culture at PNPS values timely work

completion over compliance with Informational Use procedure guidance.
Entergy developed the following key corrective actions in the apparent cause
evaluation:
CR-PNP-2016-02059 CA-16, 17, 18: Senior site leadership issued and

communicated, via an all-hands meeting, a Procedure Use and Adherence
Expectations document. This document covered procedure use and
adherence expectations for Informational Use, as well as Reference Use
and Continuous Use procedures.
CR-PNP-2016-02059 CA-19: Senior site leadership required a signed

acknowledgement of the expectations by all staff at a supervisor and above
level that stated they had not only received, but understood those
expectations as well.
CR-PNP-2016-02059 CAs-31 40, 42, 43: Site department managers

communicate senior managements procedure use and adherence
expectations once per quarter for a year.
CR-PNP-2016-02059 CA-21: Maintenance Manager initiate weekly meetings

with scheduled most error-likely task observers to provide expectations for
human performance observations, including observation of procedure use
and adherence with informational use procedures.
CR-PNP-2016-02059 CA-28: Create a new 95003 human performance

What it Looks Like (WILL) sheet to include procedure use and adherence
observation attributes.
CR-PNP-2016-02059 CA-29: Perform observations using the 95003 human

performance WILL sheet concurrently with the performance of human
performance observations for the assessment period of one year (until
June 1, 2017), or until closure of EFR PNPLO-2016-0002 CA-13.
Enclosure
87
CR-PNP-2016-02059 CAs-2227: Develop trend codes for procedure use

and adherence associated with informational use, reference use, and
continuous use procedures; train all department performance improvement
coordinators on how to use the trend codes; and incorporate procedure use
and adherence issues into the Aggregate Performance Review Meeting.
In addition, Entergy established an EFR that was scheduled to be completed by June

2017. The EFR was expected to review a monthly snapshot of IP 95003 Human
Performance WILL sheets specific to procedure use and adherence over the period
specified. The identified success criteria was an improving trend over the
assessment period.
The NRC team reviewed Entergys procedure use and adherence apparent cause
evaluation (CR-PNP-2016-02059) as well as completed and planned corrective
actions. The NRC team also interviewed PNPS personnel (maintenance, operations,
and management), observed pre-job briefs for maintenance and surveillance
activities, and observed the performance of those maintenance and surveillance
activities. Furthermore, the NRC team observed the use of the IP 95003 Human
Performance WILL sheets and interviewed those supervisors who had completed
most error-likely task observations and used those WILL sheets.
Overall Assessment for the Procedure Use and Adherence Problem Area
The NRC team concluded that identification of procedure use and adherence as a
problem area was appropriate, and continued to be appropriate as the NRC team
identified that PNPS continued to experience problems with procedure use and
adherence, especially with informational use procedures. These problems were
continuing despite most of the corrective actions developed for the apparent and
contributing causes having been implemented by Entergy. The NRC team identified
that Entergy was not monitoring the monthly snapshot IP 95003 Human Performance
assessments, as discussed in Section 6.2.1. The NRC team also identified that
corrective actions for Contributing Cause 3 were not adequate. Each of these issues
is discussed in more detail below.
Examples of Continued Procedural Adherence Issues
The following were instances reviewed or identified by the NRC that demonstrate a
continued issue with the stations performance related to procedure use and
adherence.
While observing a paired observation on November 28, 2016, using

continuous use Procedure 8.E.29.1, Salt Service Water Instrumentation
Calibration and Functional Test, Revision 19, the NRC team found several
instances where the technician did not follow and worked around procedure
weaknesses. For example, a step in the procedure was not completed, as
tygon tubing was left in place instead of being removed. This was
rationalized by the technician because the following step directed the
Enclosure
88
technician reinstall the tube. The paired observer and the supervisor were
interviewed and Entergy wrote CR-PNP-2016-09303 to address these items.
While preparing for a paired observation, the NRC team identified that the
risk for a degraded voltage test was improperly assessed as low, instead of
high, as required by Entergy procedure EN-WM-104, On-Line Risk
Assessment, Attachment 9.3, due to the associated 24-hour technical
specification limiting condition for operation. Following questions by a
member of the NRC team observing the activity, the station realized the
appropriate risk categorization and deferred the job until the appropriate,
procedurally required actions (e.g., Critical Evolution Meeting, etc.) could take
place. The NRC team determined this issue was minor because it only
affected integrated risk, a process that dictates requirements for items such
as work oversight, preparation meetings, review/approval, etc., and did not
impact the reactor safety risk assessment required by 10 CFR
50.65(a)(4). Entergy documented this issue in the corrective action program
as CR-PNP-2016-09739.
The NRC team identified that informational use procedure EN-WM-104, On

Line Risk Assessment, Revision 15, was recently revised and approved on
December 1, 2016, but as of December 6, 2016, the site continued to use
Revision 14 of the procedure. Entergy documented this issue in CR-PNP-
2016-09666. The issue was corrected the same day.
On January 4, 2017, while discussing trend reviews and EN-LI-121,

Trending Performance and Review Process, one of the Entergy team
members used the wrong revision. This is an informational use procedure.
On January 11, 2017, the NRC team identified an inadequate shift manager
turnover where the on-coming shift manager failed to sign into the logbook
prior to the off-going shift manager leaving the site. The shift managers did
perform a face-to-face turnover and did walk down the control room panels,
and at no time was the control room without a shift manager. The NRC team
determined that this turnover was not in accordance with informational use
procedure EN-OP-115-03, Shift Turnover and Relief, Revision 2. Entergy
entered this issue into the corrective action program as CR-PNP-2017-00445.
This issue is discussed further in Section 6.4.
Assessment of Apparent Cause Evaluation, Identified Causes, and Corrective

Actions
The NRC team reviewed the apparent cause and determined that in general, the
identified causes and corrective actions appeared adequate, and, if properly
implemented and enforced, should result in improved performance in procedure use
and adherence. However, the NRC team noted weaknesses in Entergys corrective
actions to address Contributing Cause 3. Entergy stated that Contributing Cause 3
was, The work culture at [PNPS] continues to value timely completion of work over
compliance with informational use procedural guidance. Entergy has taken, or
plans to take, the following corrective actions to address this issue:
Enclosure
89
Distribute senior site leaderships procedure use and adherence expectations

document
Present senior site leadership expectations at one all-hands meeting
Perform (and continue to perform) 95003 Human Performance WILL sheet

observations to observe and coach procedure use and adherence activities
during most error-likely task activities
Discuss the procedure use and adherence expectations during pre-job briefs
The NRC team determined that although the corrective actions detailed above had
been implemented, and the work staff was aware of managements expectation,
Entergy continued to struggle to demonstrate consistent performance in procedure
use and adherence area. The NRC team determined that in some cases, station
management did not always schedule and plan work to provide high assurance that
station staff could succeed. For example, the performance of a degraded voltage
surveillance activity was scheduled on the due date (November 30, 2016) and the
staff knew that if the surveillance activity was not performed by midnight, the station
would be in a 24-hour shutdown technical specification limiting condition for
operation. The surveillance test included the completion of four similar attachments
for four channels of equipment. The NRC team observed the performance of the first
attachment, which required about2 hours to complete. The maintenance crew
continued with the other three attachments after the NRC team completed their in-
field observation. The NRC team reviewed the test records the next day and
discovered that the remaining three attachments cumulatively required only about
2.5 hours to complete. The NRC team attributed the difference in time required to
perform the attachments on the remaining channels to time pressure, due to the
impending 24-hour technical specification action statement; the fact that the last
three channels were not being observed by the NRC team; and work scheduling,
which placed the workers in a position where they felt that they needed to complete
the activity as soon as possible. The NRC team reviewed the scheduling of this
surveillance and found that the activity was originally scheduled a couple of days
prior, though still very close to the deadline for completion. However, the
surveillance test had to be rescheduled due to an emergent issue requiring
movement of a control rod drive unit. Sometimes, the scheduling of work items had
such little margin that any perturbation placed the site in a must complete situation
and potentially pressured the workers to complete these tasks with minimal time.
The NRC team observed a pre-job brief for a logic system functional test on
December 1, 2016, which was to be performed by the same group of workers that
worked the evening before and performed the degraded voltage surveillance test.
Due to a needed procedure change stemming from an EC, and limited time to
complete the task due to fatigue rule requirements, the logic system functional test
was postponed. The NRC team interviewed the workers and determined that not
only was there a lack of qualified technicians to perform these type of surveillances,
the station was not likely to staff more fully-qualified technicians in the future due to
the planned permanent plant shutdown in 2019. The NRC team also determined
that the logic system functional test would normally be completed in about 4 hours,
although the work week schedule had the activity scheduled for 8 hours. The
Enclosure
90
supervisor, when asked directly, stated that the activity would take the better part of
8 hours. It was apparent to the NRC team that the workers were completing the
surveillance in much less time than the scheduled duration or what was expected by
supervision for the activity. Based on interviews with the maintenance manager, the
NRC team learned that additional resources appeared necessary in some
maintenance departments, including instrumentation and control, and the electrical
lab group. Entergy documented this observation in CR-PNP-2017-00365. The NRC
team observed that there were apparent limitations in the number of well-qualified
personnel in some areas of maintenance.
The NRC team also explored the needed procedure change that delayed the logic
system functional test surveillance activity. The NRC team determined that there
were numerous maintenance procedures that were planned for enhancement. The
NRC team did not identify any procedures that could not be performed as written;
however, nearly all of the maintenance procedures reviewed required some identified
enhancement to remove human error performance traps or to better represent how
the activity was to be implemented. The NRC team further discovered that there are
multiple processes available to change procedures, but none appear to be very
effective, and the backlog of procedure changes are not effectively tracked or
managed to completion. Entergy documented this observation in CR-PNP-2017-
00295.
These examples, coupled with the information discussed in Section 6.13 (Work
Management Problem Area) related to scheduling of work at the station, led the NRC
team to conclude that while station management was communicating the importance
of procedure use and adherence over the timely completion of work, in actual
practice, station management had not yet aligned the programs, processes, and
resources to ensure that the workers were positioned for success to value procedure
use and adherence, especially informational use procedures, over timely
completion of work activities. Entergy initiated CR-PNP-2017-00296 and CR-PNP-
2017-00399 to evaluate this NRC-identified concern.
Assessment of the Planned EFR
The NRC team identified that the monthly snapshot 95003 Human Performance
Assessments indicated that performance in procedure use and adherence was
stagnant, and had not improved since inception. Furthermore, with the exception of
NIOS, Entergy had not been reviewing these assessments, and was not aware of
this stagnant performance. Therefore, Entergy was not taking any corrective action
to evaluate and improve performance. The NRC team informed Entergy of this
observation at about the same time that NIOS informed the station of this issue as a
part of the IP 95003 corrective action follow-up. Entergy acknowledged that the
station was not reviewing the monthly snapshot 95003 Human Performance
Assessments, did not recognize the stagnant trend, and did not evaluate corrective
actions. Entergy wrote CR-PNP-2016-10326 and subsequently closed this CR to
CR-PNP-2016-02059. Entergy added corrective actions to the CR-PNP-2016-02059
corrective action plan to review the monthly assessments and to incorporate CR
trend reviews.
In addition to identifying that the trend for procedure use and adherence had not
improved, the NRC team identified, from the review of the monthly snapshot 95003
Enclosure
91
Human Performance Assessments, that the number one at-risk observation in the
assessments was the failure of supervisors and workers to stay in their roles and
responsibilities. Entergy had not identified this issue. The NRC team communicated
to Entergy that the failure to identify that staff were not maintaining their roles and
responsibilities represented an opportunity to, on a real-time basis, impart
expectations for procedure use and adherence as well as get the immediate
feedback as to why the staff felt the need to step out of their roles. Maintaining roles
and responsibilities was key in improving plant performance, but had gone
unrecognized because the snapshot assessments were not being reviewed. Entergy
initiated CR-PNP-2017-00366 to evaluate the NRC-identified concern.
6.2.4 NRC Findings
6.3 Operability Determinations and Functionality Assessments
During the stations 95003 recovery evaluations, Entergy determined a standards

performance deficiency existed in the area of operability determinations. The
Collective Evaluation Team determined that there was insufficient data to support an
elevation of this deficiency to a fundamental problem or a problem area. Specifically,
the issue identified was that operability determinations and functionality assessments
did not always meet the requirements of Entergy procedure EN-OP-104, Operability
Determination Process. Entergy issued CR-PNP-2016-01340 for this issue,
classified the CR as a Category B, and performed an apparent cause evaluation.
Entergys final apparent cause evaluation documented the following causes:
Apparent Cause: Licensed senior reactor operators had less than adequate
task knowledge for performance of operability determinations and
functionality assessments. The site management had failed to ensure that
the licensed senior reactor operators at PNPS had sufficient knowledge,
skills, and abilities to perform the safety significant task of operability
determinations and functionality assessments accurately and consistently.
Contributing Cause 1: The workload for performing operability

determinations and functionality assessments exceeds the capacity of the
normal senior reactor operator shift complement to perform high quality
determinations during periods of peak activity.
Contributing Cause 2: PNPS management has not been sufficiently intrusive

in the operability determination and functionality assessment process and
have allowed incomplete and inadequate operability determinations and
functionality assessments to go unidentified and unchallenged.
Entergy developed the following key corrective actions:
CR-PNP-2016-01340 CAs-70-73: Subject matter expert to construct a

training course that included training on the operability determination process
Enclosure
92
and very task-specific training on the stations operability determination

procedure, EN-OP-104, Operability Determination Process. The initial and
continuing senior reactor operator training programs were revised to
incorporate the new training on the operability determination and functionality
assessment process. Once revised, all senior reactor operators, including
those in initial licensing class, were trained.
CR-PNP-2016-01340 CA-10: Establish an industry subject matter expert

operability determination/functionality assessment mentor to provide daily
oversight and one-on-one coaching on operability determinations and
functionality assessments for shift senior reactor operators.
CR-PNP-2016-01340 CA-35: Establish an Operability Determination

Challenge Review Board. This board will review all CRs and all operability
determinations and functionality assessments every business day, grade the
quality of the operability determination/functionality assessment, and
communicate results to each of the operating crews on a weekly basis. The
intent of this board is to provide consistent, sustainable oversight to the
operability determination and functionality assessment process.
CR-PNP-2016-01340 CAs-78, 79: Develop and implement a plan to

supplement the control room staff during normal business hours with a
licensed senior reactor operator once the next class of senior reactor
operators receive their NRC licenses in March 2017. PNPS implemented an
interim corrective action to supplement the control room staff by assigning a
contracted subject matter expert to assist in developing operability
determinations and functionality assessments on a daily basis.
Entergy established an EFR that consisted of quarterly snapshot assessments of the

monthly roll-ups of the weekly Operability Determination Challenge Review Board
observations. The EFR was to review only the third and fourth quarter 2016
snapshots for improved performance.
The NRC team performed a thorough review of Entergys operability

determination/functionality assessment apparent cause evaluation, as well as the
completed and planned corrective actions as stated in CR-PNP-2016-01340. The
NRC team interviewed senior reactor operators, shift managers, operations and
assistant operations managers, other staff who are familiar with the operability
determination and functionality assessment process, and the subject matter expert
hired to be the mentor for this process. The NRC team also observed numerous
Operability Determination Challenge Review Board daily meetings.
Additionally, the NRC team reviewed and assessed the adequacy of Entergy
procedure EN-OP-104, Operability Determination Process, the CRs closed to CR-
PNP-2016-01340, the current operability determination and functionality assessment
program, and longstanding operability decision-making issues.
Enclosure
93
Overall Assessment of Operability Determinations and Functionality Assessments
The NRC team concluded that the identification of a standards performance

deficiency in the area of operability determinations and functionality assessments
during the stations recovery evaluations was appropriate. Entergy has implemented
a significant number of corrective actions to improve the technical competence of the
licensed senior reactor operators who perform and approve operability
determinations and functionality assessments; to improve management oversight of
the operability determination and functionality assessment program and associated
products; and to supplement the normal dayshift operating crew with additional
resources to assist with the workload. The NRC team determined that PNPS had
made significant improvements in the application and implementation of the
operability determination and functionality assessment program. However, the NRC
team also concluded that Entergy continued to have some issues with the operability
determination and functionality assessment process related to the technical rigor and
quality of engineering support. This was evident in the NRC-identified issues that
are discussed in Section 6.3.4 of this inspection report.
The NRC team determined that Entergy had established a well-defined and
prescriptive procedure that provided appropriate guidance for conducting operability
evaluations. The NRC team selected portions of the operability procedure to verify
that it appropriately incorporated guidance available in the industry including the
information contained in NRC IMC 0326, Operability Determinations & Functionality
Assessments for Conditions Adverse to Quality or Safety, dated December 3, 2015.
Assessment of the Apparent Cause Evaluation, Identified Causes, and Corrective

Actions
The NRC team reviewed the apparent cause evaluation and determined that the
identified causes and corrective actions appeared to be adequate. The corrective
actions planned and taken have resulted, and should continue to result, in improved
performance in implementation of the operability determination program. Entergy
developed an operability determination and functionality assessment improvement
action plan to address the lack of technical competency for the licensed senior
reactor operators and to address operations management oversight of the program.
The last contributing cause related to workload exceeding the capacity of the normal
senior reactor operator shift compliment to perform high quality operability
determinations and functionality assessments was being addressed by a staffing
plan that, as of the date of this inspection, had not been developed in writing.
However, the NRC team discussed the concept of the plan in an interview with the
manager of operations.
Assessment of Actions to Address the Apparent Cause: Task Knowledge
Entergy hired a subject matter expert with substantial experience in developing and
implementing operability determination programs and processes. The subject matter
expert had previous experience with sites that had undergone NRC IP 95003
recovery efforts. The subject matter expert assisted in the apparent cause
evaluation, and in developing and implementing interim and final corrective actions.
Enclosure
94
As an immediate, interim corrective action, the contractor served as a mentor for the
senior reactor operators on shift. This individual spent most of his time in the control
room advising and coaching the senior reactor operator staff. The subject matter
expert also developed training to improve the skills of senior reactor operators to
perform quality operability determinations and functionality assessments. The NRC
team reviewed the training materials and determined them to be adequate for the
stated purpose.
Entergy also developed several other operator aids to assist the senior reactor
operators in developing quality operability determinations and functionality
assessments and to ensure the correct determination on operability was made.
These operator aids included:
Development of a template to be used in the corrective action program to

ensure that all applicable operability determination and functionality
assessment items were properly addressed for compliance with EN-OP-104,
Operability Determination Process, and NRC IMC 0326, Operability
Determinations & Functionality Assessments for Conditions Adverse to
Quality or Safety
Development of a list of Maintenance Rule systems and components (safety-

related and non-safety-related) that were classified as high risk
Development of a list of mission times for safety-related structures, systems,

and components
Based on interviews, the NRC team determined that all licensed senior reactor
operators demonstrated that these job aides were not the final word on operability
input, and that they alone were responsible for making accurate and timely
operability determinations.
The NRC team determined that the corrective actions described above had
enhanced the ability of the licensed senior reactor operators to properly implement
the operability determination and functionality assessment program, and their ability
to produce accurate operability determinations and functionality assessments.
However, the NRC team determined that more improvement was needed in
implementing the operability determination and functionality assessment process.
Specifically, the NRC team identified some examples where operations had failed to
enter the operability determination process, and/or engineering failed to provide
adequate operability input, in that the input lacked technical rigor and proper review
of the current licensing basis (see Section 6.3.4). It is important to note that the NRC
team determined the cross-cutting aspect, the cause that contributed most to the
performance deficiency, was in the area Human Performance, associated with
Teamwork. Although not the only possible cause, the NRC team determined that the
operations and engineering departments did not demonstrate a strong sense of
collaboration and cooperation with respect to holding each other accountable to
ensure nuclear safety was maintained.
Enclosure
95
Assessment of Actions to Address Contributing Cause 1: Workload
Entergy implemented interim compensatory measures to address this contributing

cause. There were two final corrective actions planned that were not yet completed
at the time of this inspection: develop a staffing plan, and implement that staffing
plan. The operations manager verbally stated that his plan would be to assign a
dayshift position to be filled, on a rotational basis, by a licensed senior reactor
operator to assist the operations crew with operability determination and functionality
assessment workload issues. This action would take place after the current initial
licensed operator class is completed in March 2017, because PNPS did not have the
resources available to support this action. As an interim compensatory measure, the
subject matter expert, initially assigned to act as a mentor to the on-shift senior
reactor operators to implement the operability determination and functionality
assessment process, was reassigned in November 2016, to assist in developing
operability determinations and functionality assessments to alleviate some of the
workload.
The NRC team did not directly assess the workload on operations. However, based
on review of the data in the cause evaluation and interviews with station staff, the
NRC team determined that some of the CRs that were written on a daily basis are
representative of a normal, expected workload. The NRC team also determined that
other departments doing work, inspections, and walkdowns of the plant could take
some action to not inundate the control room with CRs at the end of the work day
(week, month, or quarter) by writing CRs as the conditions are identified, and by
better planning engineering and maintenance walkdowns so that they were
distributed throughout the week, month, or quarter instead of being conducted at the
end of the period.
Assessment of Actions to Address Contributing Cause 2: Management Oversight
As part of the Operability Determination Process/Functionality Assessment

Improvement Action Plan, PNPS established an Operability Determination Challenge
Review Board. The Operability Determination Challenge Review Board description,
purpose, function, and responsibilities were added to station procedure 1.3.34,
Operations Administrative Policies and Processes, Revision 141, and approved on
April 16, 2016. The boards main goal was to provide oversight of the operability
determination and functionality assessment process to maintain and enhance the
quality of the process and to ensure compliance with EN-OP-104 and NRC IMC
0326. The Operability Determination Challenge Board required attendance was
operations management (manager of operations and/or assistant operations
managers), and optional attendance by the operations department performance
improvement coordinator, reactor engineering, and the control room shift manager.
The board usually met daily on normal workdays, reviewed all CRs and operability
determinations/functionality assessments performed, and looked for complete,
accurate, and thorough documentation. These operability
determinations/functionality assessments were graded (if deficient) according to the
grading sheet developed and attached to the 1.3.34 procedure. The grading was on
a scale of 1 through 5, with 1 being acceptable as written and 5 being a significant
noncompliance. If the operability determination/functionality assessment was graded
as a 5, it was immediately amended and a CR was initiated to document the
performance. PNPS tracked the results and provided feedback to the specific
Enclosure
96
operations crews on a weekly basis. These weekly reports were then rolled-up
monthly and were used in a monthly operations crew metric. These metrics were
used to evaluate operations crews performance and also provided an input into the
Operations Department Performance Review Meeting report.
Because this was a significant corrective action, the NRC team observed most
meetings while on site and interviewed a number of individuals on the Operability
Determination Challenge Review Board, as well as other knowledgeable individuals.
Overall, the NRC team determined that the establishment of the Operability
Determination Challenge Review Board was an appropriate corrective action. The
NRC team also observed challenging and critical reviews of the operability
determinations/functionality assessments. However, there were some items that
passed through the Operability Determination Challenge Review Board (see Section
6.3.4) and, if left uncorrected, would have resulted in an inadequate operability
determination or functionality assessment.
From a review of these corrective actions, the NRC team has two concerns in this
area: the required composition of the Operability Determination Challenge Review
Board, and the sustainability of the board and metric tracking since this corrective
action was not a CAPR. The required composition of the Operability Determination
Challenge Review Board consisted of two operations personnel. The NRC team
concluded that the narrow staffing of the board created a missed opportunity to gain
a variety of perspectives from other departments with a vested interest in the quality
of operability determinations. The advantages of this would be that those
departments could see how their input was incorporated into the operability
determination/functionality assessment process; better determine what type and the
quality of input was required and expected by operations to ensure that an
appropriate and accurate operability determination is made; and to increase
accountability. Given that engineering was often tasked with providing input to
operability determinations, engineering should be considered to participate on this
board. Because operability and reportability are similar and related, the NRC team
determined that licensing department participation would also add value. The NRC
team noted that licensing made an effort to attend and participate on the board,
although their presence was not required.
The NRC team also had a concern with the sustainability of the Operability
Determination Challenge Review Board and metric tracking. The board had been
incorporated into station procedures, but could be easily eliminated or modified to
curtail its effectiveness. The manager of operations verbally committed to conduct
the board until the planned cessation of operations in 2019. The NRC team also had
concerns related to metric tracking. The NRC team inquired about the fact that the
subject matter expert was performing all the tracking for the Operability
Determination Challenge Review Board, even though the subject matter expert was
only contracted until May 2017. The operations manager stated that the operations
department performance improvement coordinator will perform that duty, although
this was not documented as such. The operations manager also stated that he
intended to suspend these metrics in the future. The NRC team considered the
above corrective actions as a positive, but would need added assurance from
Entergy that these actions would remain in place.
Enclosure
97
Assessment of the Planned EFR
Entergy developed and implemented an Operability Determination/Functionality

Assessment Improvement Plan on April 20, 2016. Part of that plan included the
development of a metric in order to begin to assess the effectiveness of the
corrective actions. Two quarterly snapshots were performed and reviewed. Based
on the review of those snapshot assessments, it appeared that operations had
improved the quality and consistency of the operability determinations and
functionality assessments. However, there continued to be a need for improvement
as discussed in Section 6.3.4. Furthermore, operations management communicated
the intent to suspend assessing this metric in the future. The NRC team was unable
to determine how performance in this area will continue to be improved without
measurement.
Programmatic Issue with Implementation of the Operability Determination Process
50, Appendix B, Criterion V, Instructions, Procedures, and Drawings. Specifically,
the NRC team identified a programmatic issue because in some cases, Entergy did
not enter the operability determination process when appropriate, and, when the
process was entered, did not adequately document the basis for operability, in
accordance with Procedure EN-OP-104, Operability Determination Process,
Revision 11.
Description. Entergy Procedure EN-OP-104, Operability Determination Process,

Revision 11, provided the process to assess operability and functionality when
degraded or non-conforming conditions affecting structures, systems, and
components were identified. EN-OP-104, Section 1.0[4] noted that the operability
determination process was used to assess the operability of structures, systems, and
components described in technical specifications. Additionally, EN-OP-104, Section
5.5[7] provided requirements for evaluating the capability of the component, system,
and integrated plant response during applicable analyzed design basis events. This
included, in part, evaluating conformance with applicable requirements of the
combined licensing basis; the magnitude of the degraded or non-conforming
condition; applicable codes and standards requirements for operability; loss of
functional capability; the effect on other structures, systems, and components; and
the capability of the structure, system, or component to meet the required mission
time. During this inspection, the NRC team identified four examples where Entergy
did not properly follow EN-OP-104 in order to appropriately determine the operability
of safety-related structures, systems, and components. Specifically, the NRC team
identified instances where Entergy did not enter the operability determination
process and/or did not document operability determinations with sufficient detail and
technical rigor to reach an operability conclusion. In each of the examples discussed
below, though the basis for operability was not adequate, all components were
subsequently determined to be operable following further evaluation.
On November 30, 2016, the NRC team questioned the operability of the A
emergency diesel generator following the loss of oil from the fan bearings and
gear oil pump, as documented in CR-PNP-2016-07443. Under work order
Enclosure
98
457101, Entergy repaired the relief valve, added oil to the system, collected
an oil sample, and completed a visual inspection, which included an
inspection of the magnetic drain plug. The visual inspection determined that
there was no damage identified from running the emergency diesel generator
without adequate oil in the radiator fan gearbox. Following a post-
maintenance surveillance run, Entergy declared the A emergency diesel
generator operable. Given that a visual inspection without any component
disassembly would not allow complete measurement and inspection of all the
vital components, the NRC team questioned the condition of the fan bearings
and gear oil pump, and thus, the capability of the diesel to perform its safety
function for the 30-day mission time. The NRC team noted that the gears
were made of stainless steel and thus, any particulate would not be found on
a magnetic plug visual examination. Additionally, Entergy did not analyze the
oil sample taken as part of the initial repair work order prior to declaring the
emergency diesel generator operable. Entergy wrote CR-PNP-2016-09546
and CR-PNP-2016-09648 to address the NRC teams concern. Entergy
subsequently analyzed the oil sample and determined that there was no
particulate in the oil and therefore no internal damage to the oil pump or the
fan gearbox. This was an example where Entergy failed to assess the
operability of the A emergency diesel generator with adequate technical
rigor to support the operability conclusion.
On December 2, 2016, while reviewing the A emergency diesel generator

radiator fan gearbox issue documented in CR-PNP-2016-07443 (dated
September 28, 2016), the NRC team identified an immediate operability
concern with the B emergency diesel generator. On September 29, 2016,
following repair of the A emergency diesel generator, Entergy visually
inspected the B emergency diesel generator and determined it to be
operable, thus completing a common cause evaluation. Subsequently, the
apparent cause evaluation related to the A emergency diesel generator
gearbox, completed on October 27, 2016, identified vibration and inadequate
thread engagement on the gearbox relief valve cap as a probable cause of
failure. Entergy had written a work order to inspect, and verify thread
engagement and stake the relief valve on the B emergency diesel generator
as a corrective measure, and had planned to execute this work order in the
spring 2017 refueling outage. Based on the new information provided by the
apparent cause evaluation, as well as a field walkdown, the NRC team
questioned the operability of the B emergency diesel generator. The NRC
team determined that Entergy did not verify or provide reasonable assurance
that B emergency diesel generator was operable following the completion of
the A emergency diesel generator causal evaluation, and thus, waiting until
the 2017 refueling outage to take corrective action was unacceptable. As a
result of the NRC teams concerns, Entergy immediately executed the work
order to ensure operability of the B emergency diesel generator, and wrote
CR-PNP-2016-09546 to address the operability concerns for the B
emergency diesel generator. This is an example where Entergy failed to
enter the operability determination process or properly assess the operability
of the B emergency diesel generator following the completion of the cause
evaluation on the A emergency diesel generator.
Enclosure
99
On December 7, 2016, the NRC team questioned the operability of the B

residual heat removal heat exchanger stemming from a leak from the upper
flange. The initial flange leak was documented in the corrective action
program as CR-PNP-2016-05785. Entergy performed an operability
determination and determined that the issue did not pose an operability
concern because the limit for leakage from emergency core cooling systems
was 0.5 gallons per minute, and the actual leak was 90 drops per minute.
PNPS only evaluated the operability for the residual heat removal system,
and did not consider other aspects of plant operation that could be impacted
by this leakage. The resident inspectors and the NRC team continued to
express concern that categorization of the system as operable was incorrect
because a degraded condition existed in the system. Entergy documented
the NRC teams operability concern in the corrective action program as CR-
PNP-2016-09725, and coded the immediate determination of operability as
Operable-Op Eval in accordance with EN-OP-104. Engineering completed
their evaluation and recommended that the condition was Operable-DNC
(operable, degraded non-conforming). According to the evaluation, a more
thorough review of the current licensing basis concluded that this condition
represented leakage of a closed loop system outside containment, contrary to
ANSI 56.2-1984, Containment Isolation Provisions for Fluid Systems.
Furthermore, Technical Specification 5.5.2 Primary Coolant Sources Outside
Containment, also prescribed a required program to minimize leakage
outside containment, and station procedure 8.A.16, RHR System Integrity
Surveillance, Revision 17, whose purpose was to identify leakage, stated
that the objective was zero leakage. This was an example where Entergy
failed to adequately document the basis for operability in that it was not
classified correctly, and engineering did not demonstrate knowledge of
current licensing basis in order to provide an adequate operability input for
leakage of closed loop systems outside containment, in addition to the
operability of the B residual heat removal system.
On January 12, 2017, the NRC team questioned the operability of both trains
of the emergency diesel generators documented in CR-PNP-2016-09945.
This CR describes an NRC concern with regards to a Seismic Class two-
over-one (II/I) classification of chain-falls and trolleys located in each
emergency diesel generator room. The initial operability determination
incorporated engineering judgement to declare the emergency diesel
generators operable because it would not pose a credible seismic II/I
concern. This initial operability determination was incorrect, as Seismic
Class II components are assumed to fail in a safe shutdown earthquake or in
an operating basis earthquake without an evaluation. Engineering then
provided operations another operability input that again used engineering
judgement in assuming that the chain-falls and the trolleys are well-
supported and that the chains would see very limited energy from seismic
motion of the monorail. The NRC team communicated to Entergy that the
PNPS Updated Final Safety Analysis Report (UFSAR), Section 12.2.3.5.1,
states that Class II structures and equipment were designed such that
interfaces with Class I structures would not result in a functional failure of that
Class I structure. This cannot be proven through engineering judgement.
In this example, operations made an inadequate operability determination
initially, then, after NRC questions, engineering failed to provide an adequate
Enclosure
100
input to operability. Entergy issued CR-PNP-2017-00357 and included a

proper engineering evaluation to be used as an input to operability of both
trains of emergency diesel generators. This was an example of Entergys
failure to adequately develop an initial basis for operability until further
challenged by the NRC team.
The NRC team reviewed these four issues in detail, interviewed involved parties, and
reviewed PNPS input and concluded that there was an issue associated with
effective communication between the operations and engineering departments that
had led to the failure to identify and properly document the basis for operability.
Operations apparent lack of questioning attitude and acceptance of engineering
input, and engineerings lack of rigor and consideration of licensing basis documents
supported this conclusion. Given the current state of the stations operability
determination process (degraded, but improving) and engineerings lack of technical
rigor, senior reactor operators did not demonstrate a challenging and questioning
attitude towards the engineering product input provided, which was used as a basis
for operability of important plant systems to ensure safety. For their part,
engineering did not fully demonstrate effective interaction with operations to obtain a
complete understanding of some issues in order to ensure that operations had
sufficient information to make a fully informed decision on operability.
Analysis. The failure to identify when to enter the operability determination process
and the failure to adequately document the basis for operability, in accordance with
EN-OP-104, Operability Determination Process, Revision 11, was a performance
deficiency. The performance deficiency was more than minor because if left
uncorrected, could lead to a more significant safety issue. Specifically, the failure to
enter and document a basis for operability could lead to not recognizing inoperable
safety-related equipment, and place the reactor at a higher risk of core damage in a
design basis accident. The NRC team evaluated the finding using Exhibit 2,
Mitigating Systems Screening Questions, of IMC 0609, Appendix A, Significance
Determination Process for Findings At-Power, and determined this finding did not
affect the design or qualification of a mitigating structure, system, or component;
represent a loss of system and/or function; involve an actual loss of function of at
least a single train or two separate safety systems for greater than its technical
specification-allowed outage time; or represent an actual loss of function of one or
more non-technical specification trains of equipment designated as high safety-
significance (Green). This finding had a cross-cutting aspect in the area of Human
Performance, Teamwork. Specifically, the operations and engineering departments
did not demonstrate a strong sense of collaboration and cooperation with respect to
holding each other accountable when performing operability determinations to
ensure nuclear safety is maintained [H.4].
Enforcement. 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures,

and Drawings, states, in part, that activities affecting quality shall be prescribed by
documented instructions, procedures, or drawings of a type appropriate to the
circumstances and shall be accomplished in accordance with these instructions,
procedures, or drawings. EN-OP-104, Operability Determination Process, Revision
11, states, in part, that the operability process is used to assess operability of
structures, systems, and components described in technical specifications. The
scope considered within the operability determination process is as follows:
Enclosure
101
structures, systems, and components required to be operable by technical

specifications; structures, systems and components not explicitly required by
technical specifications; and structures, systems, and components that provide
support functions required for the operability. Contrary to the above, from
November 30, 2016, through January 12, 2017, PNPS did not accomplish activities
in accordance with Entergy Procedure EN-OP-104 in that the station did not
appropriately use the operability process to assess the operability of the emergency
diesel generators and the B residual heat removal heat exchanger. Because this
finding is of very low safety significance (Green) and has been entered into the
corrective action program as CR-PNP-2017-00626, this violation is being treated as
a non-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy.
(NCV 05000293/2016011-04, Programmatic Issue with Implementation of the
Operability Determination Process)
6.3.5 Other NRC Inspection Results
The NRC team reviewed other recent NRC inspection reports and noted findings
related to PNPSs implementation of EN-OP-104, Operability Determination
Process:
In NRC Inspection Report 05000293/2016003 (ML16319A206), the

inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix
B, Criterion V, Instructions, Procedures, and Drawings, because Entergy did
not adequately assess operability as required by EN-OP-104, Operability
Determination Process. Specifically, the station did not evaluate the
operability of emergency diesel generator B when opening a cabinet door
containing relays that serve a safety function.

not perform an immediate operability determination and adequately evaluate
the operability of primary containment isolation valves in accordance with
procedure EN-OP-104.

not perform a prompt operability determination and adequately evaluate the
operability of a recirculation flow converter in a timely manner in accordance
with procedure EN-OP-104. As a result, Entergy allowed this flow converter
to remain in service, without reasonable assurance of its capability to perform
its required safety function, from October 3, 2016, until the component was
declared inoperable and replaced on October 21, 2016.
Enclosure
102
6.4 Operations Department Standards, Site Ownership, and Leadership
The NRC team observed control room operations, surveillances, shift turnover,
reactivity briefs, pre-job briefs with maintenance, the control room response to a
medical emergency, reactivity changes, and plant monitoring. The NRC team
performed interviews with auxiliary plant operators, reactor operators, senior reactor
operators, operations management, and maintenance and licensing personnel. In
addition, the NRC team observed operator requalification simulator and classroom
training, attended morning plan-of-the-day meetings, daily Operability Determination
Challenge Review Boards, Performance Improvement Review Group meetings, T-2
work meetings, and Critical Evolution Meetings.
Overall, the NRC team determined that the operations staff at PNPS operated the
plant safely, within design basis limits, and in a manner granted to them in their
license. However, numerous examples observed by the NRC team and the resident
staff indicated a lack of formality, appropriate technical specification usage, and
attention to detail for implementation of administrative programs. Some of the
examples observed by the NRC team and the resident inspection staff included:
Operations staff failed to make a 10 CFR 50.72 notification to the NRC for a
technical specification required shutdown, as required by Technical
Specifications 3.7.A.5 and 3.7.A.2.b, for two main steam outboard isolation
valves inoperable (2D and 2C). PNPSs position was that they were able to
close 1C, but chose not to do so. Therefore, they could meet Technical
Specification 3.7.A.2.b and were shutting down to repair the two main steam
isolation valves. PNPS documented this concern in CR-PNP-2017-00288
and CR-PNP-2017-01767. This issue will be dispositioned in the first quarter
2017 resident inspector report.
In some cases, operations management and staff exhibited a general lack of

formality in the main control room, including announcing of alarms, leaning on
the balance of plant control board during startup, and disruptive behavior at
the back panels that interrupted a shift reactivity briefing. In one of these
cases, the training manager commented that the same behavior was
observed during training as well. These behaviors were contrary to Entergy
procedure EN-OP-115, Conduct of Operations, which required that
operations activities be performed in a professional manner that contributes
to safe and reliable plant operations, and that personnel maintain a focused
business-like approach to assigned duties. In each of these cases, the
behaviors were not addressed by station or operations management until
questioned by the NRC. These examples demonstrated that low
expectations for formality and professionalism were being endorsed and not
corrected by the organization. Entergy documented these issues in CR-PNP-
2017-00297, CR-PNP-2017-02003, and CR-PNP-2017-04475.
Enclosure
103
The NRC team observed a face-to-face shift manager turnover and board
walkdown, and noted that the on-coming shift manager went to a meeting
and did not sign into the electronic logbook until 25 minutes after the off-going
shift manager left the control room. The on-coming shift manager signed in
as of 7:00 am without annotating it was a late entry. This was contrary to
Entergy procedure EN-OP-115-03, Shift Turnover and Relief, Revision 2,
which states that the off-going shift manager will not leave the work area until
their relief has successfully assumed the watch by annotating it in the station
logs. The NRC team communicated this to the operations manager, who
stated that this was not an unusual occurrence. Entergy entered this issue
into the corrective action program as CR-PNP-2017-00445. The NRC team
determined that this issue was minor because there was not any time where
an operations shift did not have a shift manager assigned. However, this
issue highlighted the acceptance of informal behaviors and non-adherence to
operating procedures by shift and operations management.
The NRC team observed a pre-job brief for an emergency diesel generator
surveillance and commented that, although the brief was adequate, it
appeared to only cover enough to meet the minimum requirements of the
associated checklist. The NRC team noted that operating experience
discussed at the briefing was not site-specific or actionable to protect against
having an issue with the surveillance. The NRC team further noted that the
worst case scenario, which discussed an inoperable emergency diesel
generator and technical specification entry, was not the worst case. The
worst case scenario would be a catastrophic failure and personnel injury.
The briefing did not communicate that there was an ongoing issue with
procedure use and adherence and what actions or tools the participants were
going to use to ensure performance that met expectations for this problem
area. The NRC teams observations were communicated and well-received
by the shift manager. By contrast, the NRC team had the opportunity to
observe a similar brief the following day and noted a clear improvement in the
quality and intensity of the brief.
The NRC team also identified an issue with keeping current, up-to-date
information in the control room for operational decision-making issues and
some long standing night orders. The NRC team identified an operational
decision-making issue for switchyard line 355 that had been resolved several
weeks prior, yet the operations staff was carrying the operational decision-
making issue on the shift turnover sheet. The NRC team also reviewed the
age of standing orders, as one was written in 2015, and requested Entergy to
review them to ensure that they were all still valid. Entergy documented this
The NRC team noted, during the first onsite inspection week (November 28
December 2, 2016), that Entergy had not yet completed their winter
readiness preparations at PNPS in accordance with procedure 8.C.40,
Seasonal Weather Surveillance, Revision 40, which stated that Attachment
1 (cold weather preparations) should be performed in the fall of each year
(September to November). Entergy completed their winter readiness
preparations on December 6, 2016. The NRC team determined that this
Enclosure
104
issue was minor because the items that were not completed did not impact
the operability of any safety-related equipment.
Based on these examples, the NRC team determined that the lack of formality was
likely a result of inadequate management standards and expectations, as well as the
operations staff having become complacent with respect to the conduct of plant
operations over a number of years. The NRC team also concluded that the
operations department had not demonstrated strong and consistent site ownership
and leadership, and had not reinforced high standards of performance, as required
by station procedures. In addition to the examples listed above, the NRC noted the
following:
The programmatic violation concerning the incomplete operability

determinations (Section 6.3.4), as well as the recent operability determination
violations identified by the resident staff (Section 6.3.5) demonstrated a lack
of ownership for some complex issues in which engineering was requested to
provide supportive information. In these examples, operations did not hold
engineering accountable to provide high quality engineering products.
The NRC team reviewed the role of operations department staff in meetings
and observed that individuals were not challenged during meetings. The
station explained to the NRC team that individuals were challenged one-on-
one outside of the meetings. The NRC team communicated that challenging
teammates in meetings was viewed as healthy and, if conducted in a
professional manner, significant gains and productivity could be realized from
other participants input. The response was, That is not how business is
conducted here.
Related to shift manager operability determination review rigor for the A SRV
issue (Section 4.7), the NRC team concluded that there was enough
information in the associated CR such that a knowledgeable senior reactor
operator could reasonably conclude that the A SRV did not open in 2013.
Further, the NRC team determined that the shift manager possessed
adequate training and knowledge to ensure an adequate operability
evaluation was completed, but did not review the operability determination
with enough rigor to identify the performance issues with the SRV.
The NRC team also reviewed the November 2016 PNPS 95003 Mentor Team
Report and interviewed the team leader. The mentor team identified an issue with
shift manager leadership in the plan-of-the-day meetings. The following is excerpted
from CR-PNP-2016-10130, which Entergy wrote in response to this monthly mentor
report:
Shift managers mostly act as meeting facilitators and do not take on

a strong leadership role in the plan-of-the-day meetings. Based on
our experience and knowledge of industry standards, we would
expect to see the shift managers leading the meeting, and the
station, by demonstrating and reinforcing high standards of
performance. Performance in this area is inconsistent. Currently,
Enclosure
105
this role is filled by the Senior Operations Manager, who usually

summarizes the meeting and provides overall direction to the team.
The planned corrective actions were to develop and implement coaching to individual
shift managers to increase leadership at plan-of-the-day meetings. The NRC team
determined that this CR and planned corrective action were appropriate in
developing leadership among shift managers. These corrective actions were
scheduled to be implemented in the spring 2017 and, as such, were not evaluated as
part of this inspection.
Entergy initiated CR-PNP-2017-01248 related to the NRC teams concerns regarding

gaps in licensed operator ownership and accountability.
Procedure Quality Key Attribute (IP 95003, Section 02.03d)
6.5 Procedure Quality Problem Area
Entergy identified procedure quality (i.e., eliminate human error traps and
administrative errors) as a problem area as a result of their collective evaluation
process. In response, Entergy performed an apparent cause evaluation and
documented the evaluation results and corrective actions to address the procedure
quality problem area in CR-PNP-2016-02058. Entergys apparent cause evaluation
documented the following:
Direct Cause: Some procedures do not comply with station procedures

1.3.4-1, Procedure Writers Guide, 1.3.4-10, Writers' Guide for Emergency
Operating Procedures, 1.3.4-13, EOP/SAG Verification Program, or 1.3.4-
14, EOP/SAG Validation Program.
Apparent Cause: Managers, superintendents, and personnel who are

assigned to review new procedures and procedure changes are unaware of
PNPS procedure standards and expectations.
Contributing Cause 1: 1.3.4-1, Procedure Writers Guide, does not include

key industry standard elements from the guidance prescribed in industry
standard PPA AP-907-005, Procedure Writer's Manual.
Contributing Cause 2: The resolution requirements of the PNPS Corrective

Action Program when applied to procedure quality issues were ineffective.
Entergy established interim corrective actions to ensure that their event response
procedures did not have any technical and/or procedure quality issues that
Enclosure
106
prevented effectively implementing the procedures. Entergy implemented the

following corrective actions to address their issues in the procedure quality problem
area:
CR-PNP-2016-02058 CA-30: Revise NOP98A1, Procedure Process, to

require new station procedures and station procedure changes be reviewed
by qualified personnel. The intent is to ensure new procedures and
procedure changes are reviewed by personnel who are qualified via training.
CR-PNP-2016-02058 CA-31: Develop and implement procedure reviewer

qualification training. The intent of this action is to institutionalize a method to
maintain procedure reviewers knowledge of PNPS procedure standards.
CR-PNP-2016-02058 CA-33: Develop and implement gap training related to

procedure quality for managers, superintendents, and procedure reviewers in
Operations, Maintenance, Chemistry, and Radiation Protection departments
CR-PNP-2016-02058 CA-32: Revise PNPS 1.3.4-1, Procedure Writers

Guide, to incorporate key industry standard elements from the guidance
prescribed in PPA AP-907-005, Procedure Writer's Manual.
CR-PNP-2016-02058 CAs-34 37: Personnel who are assigned to review

new station procedures or station procedure changes scoped under PNPS
1.3.4-1, Procedure Writers Guide, shall be qualified to perform reviews. At
least two workers from each responsible department will be trained and
qualified. The intent of this action is to ensure personnel who review new
procedures and procedure changes are trained and qualified to perform those
duties in accordance with PNPS procedure standards and expectations.
Also, the intent is to ensure new procedures or procedure changes submitted
by any worker at the station or contractors will be reviewed by a qualified
individual for compliance to PNPS procedure standards and expectations.
CR-PNP-2016-02058 CAs-40 45: Assign qualified personnel to review

procedures used for activities that place the station in an integrated risk
above normal. The intent is to ensure these procedures are workable as
written and in compliance with PNPS 1.3.4-1, Procedure Writers Guide.
The NRC team evaluated the procedure quality problem area to determine whether
PNPS: (1) correctly identified procedure quality as a problem area, (2) appropriately
identified apparent and contributing causes, (3) established appropriate corrective
actions identified to address the apparent and contributing causes, (4) adequately
implemented corrective actions, (5) identified EFR(s) that adequately assessed the
effectiveness of the corrective actions, (6) adequately performed any EFRs,
and (7) effectively addressed the overall problem.
Enclosure
107
In addition, the NRC team reviewed, evaluated, and assessed the following specific
areas:
The process used to develop and revise procedures, and the process used to
incorporate procedure feedback, including changes classified as non-intent
changes.
Emergency operating procedures for procedure quality and adequacy.
Other procedures for quality and accuracy, with specific samples from the
residual heat removal and on-site emergency alternating current power
systems.
The process used to develop and control temporary procedures and

temporary procedure changes, including whether Entergy established limits
on how long a temporary procedure can be in effect and whether this
compares with observed practices.
Internal assessments and external assessments associated with the vendor

manual program and whether Entergy had corrected any identified
deficiencies.
Whether Entergy maintained vendor manuals up to date and appropriately

incorporated vendor manual requirements into procedures/work orders.
Recently completed work orders and open work orders to determine whether
these work orders incorporated vendor manual requirements, as appropriate.
Use of the corrective action program when processing procedure changes.
Adequacy of the procedure implementing the operability process.
Adequacy of the comprehensive recovery plan metrics to provide meaningful

information to track recovery.
The NRC team conducted this inspection through a review of records, procedures,
procedure changes, corrective action documents, vendor manual changes, process
evaluations, and interviews. The NRC team evaluated whether each corrective
action had been effectively implemented.
Procedure Quality Process
The NRC team determined that Entergy correctly assessed procedure quality as a
problem area. Entergy considered this a problem area since procedures that did not
meet current industry standards contained human error traps that could lead to
mistakes when personnel performed the procedures. These written procedures
included human error traps such as action steps in Notes and Caution statements
or multiple actions in a single step. Entergy performed a thorough review of
Enclosure
108
procedure issues during their collective evaluation process by evaluating a broad

range of procedures that affected both safety-related and important to safety
components. The NRC team listed the procedures reviewed by Entergy during the
collective evaluation process in Table 1, Procedures with Quality Issues, located in
the Attachment to this report. The NRC team verified that Entergy properly assigned
the negative observations into standards performance deficiencies and into
standards performance deficiency roll-ups. The apparent cause analysis identified
appropriate direct, apparent, and contributing causes.
The NRC team determined that Entergy had reviewed approximately 207 of their 602
maintenance procedures in response to a different deficiency documented in CR-
PNP-2013-01566. The 207 procedures included procedures for equipment that
Entergy identified as trip-sensitive or would increase integrated risk above normal.
The NRC team determined that the procedures upgraded during these reviews
included revisions to correct technical as well as procedure quality issues. Also,
operations had reviewed 61 out of 125 procedures as part of an extent of condition
evaluation related to declining performance, as described in a mid-cycle assessment
letter. As part of the recovery plan, Entergy performed interim corrective actions that
included reviewing and revising any of the remaining 64 operations procedures that
had procedure quality or technical deficiencies.
The NRC team determined that, generally, Entergy established appropriate

corrective actions to address the apparent cause. Entergy revised their procedure
process to add a procedure quality review intended to ensure procedures met the
procedure writers guide, which they had upgraded to current industry standards.
Entergy identified six work groups (operations, mechanical, electrical and
instrumentation and control, maintenance, chemistry, and radiation protection) that
had procedures that required review. Entergy developed a standard set of technical
and procedure quality questions, in the form of a WILL sheet, to assess their
procedures against rating criteria. Entergy had established that procedures
associated with maintenance activities scheduled at the work management T-10
milestone (i.e., 10 weeks prior to the work implementation week) would be assessed
and evaluated by each of the work groups to determine if they required revision.
Entergy selected this milestone to assure that any procedures that required revision
in order to be technically feasible for implementation had sufficient time to be
corrected. The NRC team identified one performance deficiency because Entergy
had not selected a sufficiently broad range of procedures that required upgrading to
meet their writers guide requirements. The NRC team documented the details
related to this performance deficiency in Section 6.5.4 of this report.
Entergy had not established any specific time limits for revising the procedures to
meet their plant writers guide for procedures that were technically adequate but had
one or more concerns related to usage quality. The NRC team expressed a concern
that the process had not established a time limit to make the changes and Entergy
initiated LO-PNPLO-2017-00002 to require monthly assessments of changes to
procedures to assess timeliness in improving procedure quality. Entergy indicated
that the procedure changes would be implemented commensurate with their safety
significance.
The NRC team determined that, with a few exceptions, Entergy had effectively
implemented their planned corrective actions as of the date of the inspection.
Enclosure
109
Though Entergy identified the need to reperform the EFR required by CR-PNP-
2015-07853 CA-23, due to not sampling 20 percent of the correct population of
revised operations procedures, the NRC team determined that Entergy did not
actually implement the reperformance of the EFR. Entergy initiated CR-PNP-
2016-09843 to document the NRC teams observation, and performed the
appropriate EFR in accordance with PNPLO-2015-00208, CA-4. The NRC team
determined this issue was minor because the EFR concluded that operations
procedures revised because of technical concerns also met the procedure quality
standards in the procedure writers guide.
The NRC team evaluated the planned EFR to assess the corrective actions related
to performing procedure quality reviews. The NRC team determined that one of the
four planned actions in the EFR required enhancement. Entergy had not established
a large enough sample population for interviewing personnel as part of the procedure
quality review process. Specifically, Entergy planned to conduct eight interviews to
include users, supervisors, and managers. The NRC team considered this number
too small a sample since the procedure revisions affected six work groups. Entergy
documented this observation in CR-PNP-2017-00419 and indicated that they would
at least triple the sample population.
The NRC team verified that Entergy provided appropriate training to managers and
supervisors, selected a minimum of two individuals from the work groups to perform
procedure quality reviews, and provided appropriate training to the identified
procedure quality reviewers. Since Entergy initiated their procedure quality review
process at the T-10 work management milestone in mid-November, the NRC team
determined that the process had insufficient time to demonstrate that it would be
effective. Specifically, Entergy had reviewed upcoming procedures and identified
some that required revision to meet their writers guide; however, the identified
procedures had not been revised. In addition, the NRC team determined that
Entergy had established a review scope that would revise the most safety and risk
significant procedures, but did not address the broad range of procedures that
resulted in identifying procedure quality as problem area. The NRC team identified a
performance deficiency since Entergy had established an inadequate procedure
quality review scope, as described in Section 6.5.4 of this inspection report.
The NRC team concluded that Entergy had appropriately identified procedure quality
as a problem area and had established corrective actions that should address the
deficiencies related to this problem area. The NRC team could not determine
whether the corrective actions effectively addressed this problem area since the
majority of the actions had not been in place for a sufficient amount of time. The
NRC team concluded that the corrective actions, if implemented properly, could
correct the deficiencies that resulted in procedure quality being a problem area.
Specific Activities Reviewed
The NRC team determined that Entergy used Procedure NOP98A1, Procedure
Process, Revision 39, to control their procedure process including revisions. The
NRC team verified that this procedure: (1) prescribed the process and established
controls for developing and revising procedures; (2) provided clear guidelines for
determining whether planned procedure changes were intent or non-intent changes;
Enclosure
110
(3) established controls and conditions for developing temporary procedures, which
included a 2-year limit for temporary procedures to remain active; and (4) required
that vendor manual instructions be incorporated as procedure steps rather than
referencing a section of a vendor manual.
To assess Entergys procedure review process, the NRC team selected:

(1) procedures associated with the residual heat removal and on-site emergency
alternating current power systems; (2) procedures identified as temporary
procedures; (3) procedure changes listed as non-intent changes; (4) procedures that
had associated vendor manual changes; and (5) work orders that implemented
preventive maintenance requirements. The NRC team determined from the review
of procedures that PNPS had established appropriate controls that ensured
personnel could identify the difference between an intent change and a non-intent
change. The NRC team determined that Entergy placed effective dates on
temporary procedure cover pages that clearly defined the expiration date of the
temporary procedures. The NRC team verified that Entergy used temporary
procedures for special tests or infrequently performed activities as prescribed in
Procedure NOP98A1.
The NRC team determined that the apparent cause evaluation for procedure quality
identified that none of the 15 negative observations impacted the ability of operators
to effectively implement their emergency operating procedures. The NRC team
reviewed the negative observations, interviewed personnel who had identified the
negative observations, and discussed the planned resolution of the negative
observations with the responsible operations personnel. The NRC team evaluated
the emergency operating procedures against the emergency operating procedure
writers guide. CR-PNP-2016-05834, CA-2 described the need to develop corrective
actions to resolve the emergency operating procedure negative observations.
During discussions with Entergy, the NRC team determined that the deficiencies
affected the writers guide, emergency operating procedures, and the procedure
design bases documents. Entergy developed specific corrective actions as part of
CR-PNP-2016-05834 to address the specific deficiencies and initiated changes to
the documents. The NRC team observed that Entergy had appropriately concluded
that the negative observations had no impact on the ability of operators to effectively
implement the emergency operating procedures.
The NRC team determined that Entergy had performed effective internal snapshot
assessments of their interim procedure quality reviews. The assessments described
the quality of procedure changes that had been developed and the progress of
procedure updates.
The NRC team reviewed the vendor manual update process. As an extent of
condition review specified in CR-PNP-2016-02061, CA-42 and CA-43, Entergy
completed a snapshot self-assessment of their vendor manual program and vendor
re-contact process (LO-PNPLO-2016-00033). The NRC team determined that
Entergy had performed a critical self-assessment that identified several standards
performance deficiencies including: (1) failure to have a significant component list,
(2) failure to have a key vendor list, (3) failure to generate a record to demonstrate
vendor re-contact had occurred, and (4) failure to establish preventive maintenance
tasks to re-contact 55 vendors. Entergy self-identified that they failed to contact 13
vendors of safety-related components within 3 years as specified in Entergy
Enclosure
111
procedure EN-DC-148, Vendor Manuals and Vendor Re-Contact Process,

Revision 6. The NRC team confirmed that Entergy had made the re-contacts during
this inspection and no significant changes to the vendor manuals resulted. The NRC
team determined this was a licensee-identified violation and documented this issue
in Section 9 of this inspection report.
The NRC team determined that Entergy had credited the corrective actions being
implemented for the corrective action fundamental problem area to address the
contributing cause identified in this apparent cause evaluation. During the review of
this area, the NRC team determined that Entergy consistently initiated corrective
action documents for procedure changes that affected technical information
contained within procedures since Entergy considered these changes as adverse.
Entergy did not consider changes that affected procedure quality as adverse since
the changes would not prevent effective implementation of the procedure. The NRC
team verified that Entergy appropriately closed non-adverse CRs to procedure
change forms. The NRC team identified no concerns with the disposition of intent
and non-intent procedure changes.
Inadequate Procedure Quality Review Scope
Introduction. The NRC team identified a Green non-cited violation because Entergy
implemented inadequate corrective actions to address the procedure quality issues
identified in CR-PNP-2016-02058. Specifically, the apparent cause identified this as
a problem area based upon a broad range of plant procedures with procedure quality
issues; however, Entergy limited the corrective actions to only those procedures that
would result in an integrated risk increase above normal.
Description. Entergys apparent cause evaluation related to procedure quality,

documented in CR-PNP-2016-02058, identified the following problem statement:
Some station procedures have technical errors and/or lack an appropriate level of
detail and human factoring. Inadequate procedure quality increases the probability
of procedure non-compliance, human performance errors and station events. The
apparent cause evaluation also stated that the direct cause of the procedure quality
problem area was that some procedures do not comply with the procedure writers
guides. Further, the extent of condition documented in the cause evaluation
recognizes that all types of plant procedures contain some level of detail, human
factoring, or administrative errors. To address the direct cause of the procedure
quality problem area, Entergy specified corrective actions only to address
procedures used for emergent work, and procedures used for activities that place the
station in an integrated risk above normal (i.e., procedures considered trip sensitive
or could result in a consequential event). Entergy did not specify corrective actions
for a number of procedures, including maintenance and/or operating procedures for
safety-related equipment.
The NRC team independently reviewed the negative observations related to

procedure quality (level of detail, human factoring, or administrative errors) and
determined that procedure quality issues affected a wide range of procedures, not
just procedures that increased integrated risk above normal. For example, 31 of the
procedures included routine system operating procedures, ventilation system
Enclosure
112
calibration procedures, and maintenance procedures (refer to Table 1 in the

Attachment to this report). Entergy procedure EN-LI-118, Cause Evaluation
Process, Revision 22, Step 5.2[8] specified that there should be a direct logical tie
between the problem statement, cause, and corrective actions. Step 5.4[1](d)
and (e) specified, in part, to ensure the problem statement contains only one problem
and use the problem statement to maintain focus. Step 5.12[5] specified that
corrective actions should be established for each identified root and apparent cause.
The NRC team determined that the corrective actions related to limiting the scope of
procedures to those that resulted in integrated risk above normal was too narrowly
focused, did not accurately reflect the conclusions of the apparent cause evaluation,
and did not completely address the identified problem and apparent cause.
Specifically, Entergy failed to establish actions that addressed the broad range of
procedures that affected safety-related equipment, and inappropriately focused the
corrective actions to only those procedures that increased plant risk above normal.
Analysis. The failure to establish corrective actions to address a condition adverse

to quality in accordance with 10 CFR Part 50, Appendix B, Criterion XVI, was a
performance deficiency. Specifically, PNPS inappropriately limited their corrective
actions to those procedures that increased integrated risk above normal, and did not
include other types of safety-related procedures that did not meet their procedure
quality standards and resulted in procedure quality being a problem area. The
performance deficiency was more than minor because it affected the procedure
quality attribute of the Mitigating Systems cornerstone, and adversely affected the
cornerstone objective to ensure the availability, reliability, and capability of systems
that respond to initiating events to prevent undesirable consequences (i.e., core
damage). The decision to limit corrective actions to procedures that increased
integrated risk above normal or trip sensitive failed to include other procedures
associated with safety-related components that reflected the broader population
reviewed during the collective evaluation.
The NRC team evaluated the finding using Exhibit 2, Mitigating Systems Screening
Questions, of IMC 0609, Appendix A, Significance Determination Process for
Findings At-Power, and determined this finding did not affect the design or
qualification of a mitigating structure, system, or component; represent a loss of
system and/or function; involve an actual loss of function of at least a single train or
two separate safety systems for greater than its technical specification-allowed
outage time; or represent an actual loss of function of one or more non-technical
specification trains of equipment designated as high safety-significant. Therefore,
the NRC team determined the finding was of very low safety significance (Green).
The NRC team determined that this finding had a cross cutting aspect related to
Human Performance, Resources, because the leaders failed to ensure that
personnel, equipment, procedures, and other resources are available and adequate
to support nuclear safety. Specifically, based on available resources, Entergy chose
to limit the scope of safety-related procedures being revised to their procedure
quality standard to only those that resulted in high integrated risk or were trip
sensitive [H.1].

states, in part, that measures shall be established to assure that conditions adverse
to quality, such as failures, malfunctions, deficiencies, deviations, defective material
and equipment, and non-conformances are promptly identified and corrected.
Enclosure
113
Contrary to the above, from June 15, 2016, through January 12, 2017, Entergy did
not establish adequate measures to correct an identified condition adverse to quality.
Specifically, the corrective actions established in the apparent cause evaluation in
CR-PNP-2016-02058 were limited to those that increased integrated risk above
normal rather than a wider range of procedures affecting safety-related components,
as identified in their collective evaluation process. Because this finding was of very
low safety significance (Green), and Entergy entered this issue into their corrective
action program as CR-PNP-2017-00400, this violation is being treated as a non-cited
violation, consistent with Section 2.3.2.a of the Enforcement Policy. (NCV
05000293/2016011-05, Failure to Establish Corrective Actions to Address
Scope of Procedure Quality Issues)
6.6 Emergency Preparedness Procedures
The NRC team reviewed a sample of Emergency Plan (Plan) and implementing
procedure changes to assess the change process and to ensure that no decrease in
the effectiveness of the Plan had occurred.
The document changes were mostly administrative or editorial in nature based upon
user input. Other document changes were process enhancements. The
effectiveness and commitments of the Plan were maintained. Implementing
procedures were determined to be capable to support the emergency response
organizations ability to protect public health and safety.
Equipment Performance Key Attribute (IP 95003, Section 02.03e)
6.7 Equipment Reliability Problem Area
During the 95003 Collective Evaluation process, Entergy identified that station
equipment performance and material condition do not meet fleet and industry
standards. These weaknesses have resulted in long-standing equipment problems
and less than adequate equipment reliability which have led to station challenges
and events. As a result, Entergy identified equipment reliability as a problem area
and conducted a root cause evaluation under CR-PNP-2016-02056 to assess the
issue. Entergys root cause evaluation documented the following causes:
Root Cause 1: Station leadership is not consistently exhibiting and

reinforcing behaviors that support the fundamental concepts of a zero
tolerance for unanticipated equipment failure.
Enclosure
114
Root Cause 2: Station leadership has failed to take action to mitigate the
plant reliability impact of reducing resources.
Contributing Cause 1: Station leadership has failed to foster and reinforce

strong teamwork and accountabilities between and within key organizations
that implement major elements of the equipment reliability processes,
specifically system engineering, maintenance, and production.
Contributing Cause 2: Station leadership did not effectively implement

change management for organizational-capacity-related changes and for
corporate procedural changes associated with the restructuring activities of
alignment (2007/8), the proposed company spin-off (2008/9), and Human
Capital Management (2013).
Contributing Cause 3: Station personnel have not effectively applied the

guidance contained in the corrective action program procedures (initiation,
evaluation, resolution) to maintain station equipment performance within
industry standards.
Contributing Cause 4: Station leadership does not consistently ensure all

applicable requirements of informational use procedures are identified and
followed.
Contributing Cause 5: Station personnel do not rigorously implement the

preparation, control, and execution of work activities such that equipment
reliability is the overriding priority.
The evaluation also determined there had been opportunities to recognize and
address the decline in equipment reliability through quality assurance audits, cause
evaluations, and external findings. However, the response efforts had not been
effective or sustainable and therefore had not adequately addressed the underlying
issues identified. Secondly, staffing had been reduced by 8 percent since 2007,
while during this same time period, the average full-time-equivalent staffing at other
small boiling water reactors had increased. Over 40 percent of the staff reduction at
PNPS was in the engineering department (i.e., greater than 20 engineering full-time-
equivalent) with additional impacts to production staffing.
Entergy identified the following significant corrective actions in the corrective action
plan:
CR-PNP-2016-02056 CA-26: (CAPR-1) Develop, approve, and issue a

PNPS specific recovery procedure to describe required actions to be
implemented by the equipment reliability mentor team put in place by
corrective action CA-RCE-2-A.
CR-PNP-2016-02056 CA-29: (CAPR-2A) Track action CR-PNP-2016-2057

CA-41 to completion. This action requires the maintenance manpower
resources be increased in order to reduce work order backlogs to meet fleet
goals.
Enclosure
115
CR-PNP-2016-02056 CA-30: (CAPR-2B) Track action CR-PNP-2016-2057

CA-42 to completion. This action requires the reassessment of action CR-
PNP-2016-2057 CA-41 to increase maintenance man-power resources to
ensure an adequate resource-loading plan for maintenance is based on the
workload expectations for the remaining 3 years of plant life.
CR-PNP-2016-02056 CA-31: (CAPR-2C) Provide supplemental support for

the systems, components, and engineering supervision functions.
The NRC team performed a review of the equipment reliability root cause evaluation
documented in CR-PNP-2016-02056, and associated corrective actions planned and
already implemented. The NRC team conducted interviews with key personnel,
including design and system engineers; performed field walkdowns to visually
inspect several safety-related systems and components to verify the material
condition of structures, systems, components, and support systems; attended
meetings associated with the plant health program; and performed a review of key
system health reports. The NRC team assessed the maintenance, calibration, and
testing of risk-significant plant structures, systems, and components. The NRC team
assessed PNPSs implementation of on-line and outage maintenance, including
backlogs; preventive maintenance scope, frequency, deferrals, technical bases, and
use of vendor recommendations and industry experience; and longstanding
equipment issues. Additionally, the NRC team assessed the effectiveness of
corrective actions for deficiencies involving equipment performance and assessed
the operational performance of selected safety systems to verify the capability of
performing their intended safety functions. The review included the following
systems and components:
Emergency Diesel Generators

Start-up Transformer
Air Operated Valves
Auxiliary Building Tours with Focus on Penetration Areas and Motors
High Pressure Cooling Injection
Decay Heat Removal System and B Heat Exchanger Flange Leakage
Safety-Related Check Valves
Safety-Related Station Batteries
480V and 4KV Power Cables: Cable Reliability Program
The NRC team concluded that PNPSs evaluation of the equipment reliability issues
documented in CR-PNP-2016-02056 was comprehensive. The evaluation provided
a critical look at the plant health program, including long term equipment reliability
and obsolescence, and identified key issues that the program had previously failed to
identify or correct. The NRC team verified an adequate extent of condition review
was also performed. In the area of equipment performance and reliability, the NRC
team acknowledged that PNPS had completed numerous efforts to improve
equipment performance and reliability. In addition, improved engineering support
and management oversight of the plant material condition and equipment
Enclosure
116
performance were noted including the implementation of a new mentoring program

with industry subject-matter experts to provide an ongoing diagnostic assessment of
plant performance. The NRC team also noted that five contract staff members were
added to engineering and six maintenance staff were added to reduce the
maintenance backlog. In addition, the NRC team verified that EFRs have been
established for identified CAPRs.
However, the NRC team identified several examples which indicated that the
resolution of degraded equipment problems and implementation of the corrective
action program continued to challenge PNPS. The NRC team determined that at this
time it is too early to assess the effectiveness of all the applicable corrective actions
because the effectiveness reviews are not all complete and the corrective actions
have only been in place for a short period of time. The need for further NRC reviews
at a later time will be evaluated to ensure the response efforts have been effective
and sustainable and have adequately addressed the underlying issues identified.
The following specific issues related to the area of equipment performance were
identified during the inspection:
The NRC team identified a finding and apparent violation associated with the
failure to adequately review a design change implemented on the A
emergency diesel generator, documented in Section 6.7.4. This issue
resulted in inoperability of the A emergency diesel generator.
During this inspection, the NRC team identified a performance deficiency

involving untimely corrective actions to address the degraded C phase cable
which supplies power to several 480V safety-related components, including
reactor building closed cooling water pumps, salt service water pumps,
emergency diesel generator oil transfer pump, reactor feed pump lubricating
oil, and the battery room exhaust fan. Specifically, since 2007, Entergy
identified a failure to meet the cable reliability (insulation resistance) Megger
testing acceptance criteria of 100 megaohms (M). In addition, triennial
Megger test results showed a degrading trend with the last reading taken in
2015 at 5.8M. The 3-phase non-shielded cable is approximately 1010 feet
long, and involves three separate manholes that are challenged with water
submergence. Additionally, each manhole contains a cable splice.
Engineering reduced the acceptance criteria to a minimum calculated value
of 1.48M and determined the cable would remain operable until its
replacement during the upcoming refueling outage (1R21) scheduled for early
2017. The NRC team did a detailed review of this issue to verify Entergy is
properly monitoring and pumping out water from the manholes as required by
Entergy procedure EN-DC-246, Cable Reliability Program. The NRC team
reviewed applicable CRs and operability determinations, interviewed the
cable reliability engineer, engaged NRC electrical experts from the
headquarters office, and held several telephone conferences with Entergy.
An Electric Power Research Institute (EPRI) representative was also present
during one of the telephone calls. The NRC team determined that Entergys
actions to address this degraded trend were untimely and were not
commensurate with the safety significance of the cable. Entergy issued CR-
PNP-2017-00755 to document the NRC teams concerns. The NRC team
concluded that this performance deficiency was minor, in accordance with
IMC 0612, Appendix B, because it did not affect the Mitigating System
Enclosure
117
cornerstone objective of availability, reliability, or capability of the system.

Based on the available data, and the absence of a cable failure, the NRC
team did not have reason to question operability of the cable or its associated
safety-related systems. In addition, the NRC team confirmed that actions to
perform detailed trouble shooting and cable replacement as necessary are
approved and scheduled for the upcoming refueling outage (1R21) as
documented in CR-PNP-2015-03909.
During this inspection, the NRC team identified a performance deficiency

involving a deficient evaluation of an operating experience review for an
emergency diesel generator jacket cooling water hose failure. On January 4,
2016, at Oyster Creek Nuclear Generating Station, an emergency diesel
generator cooling water flexible coupling hose ruptured during a biweekly
surveillance test, which resulted in low coolant pressure and subsequent
inoperability of the emergency diesel generator (See NRC Inspection Report
05000219/2016001 (ML16132A436)). On June 20, 2016, Entergy completed
an evaluation of this operating experience issue under OE-NOE-2016-00103,
CA00015 and determined that their ALCO emergency diesel generators have
many non-metallic hoses (approximately 38) associated with lubricating oil,
jacket water, and air (starting/turbo assist) systems that were susceptible to
the same type of failure. The NRC team noted that Entergy credited their
preventive maintenance program, which requires replacement of all the
emergency diesel generator hoses at an 8-year frequency, without doing any
verification that the 8-year frequency was being properly implemented. The
NRC team interviewed the emergency diesel generator system engineer,
reviewed applicable hose replacement work orders, and performed
walkdowns of both emergency diesel generators to visually inspect the
condition of all the hoses. The NRC team noted that Entergy had replaced
most of the non-metallic hoses on both emergency diesel generators
between 2010 and 2011, but could not find documentation to confirm that
several air hoses (starting air/turbo assist) had been replaced. The NRC
team was concerned that these flexible hoses may have been in service for
approximately 42 years and subjected to thermal degradation and aging that
could eventually lead to failure and potentially impact emergency diesel
generator operability. Entergy performed an immediate operability evaluation
under CR-PNP-2017-00341 and CR-PNP-2017-00370 (A and B emergency
diesel generators, respectively) and determined that a failure of any of the
affected hoses would not severely impact the operability of the emergency
diesel generators and that this condition is considered non-conforming but
operable. The NRC team reviewed this information and determined that
Entergys conclusions were acceptable. Additionally, the NRC team
performed a walkdown of the emergency diesel generators and observed that
the hoses appeared to be in good condition. Entergy initiated actions to
replace the applicable hoses during the upcoming refueling outage (1R21).
The NRC team determined that failure to ensure the vendor recommended 8-
year replacement frequency of the emergency diesel generator non-metallic
hoses was a performance deficiency. Based on the observed good condition
of the hoses, the results of Entergys operability evaluation, and adequate
monthly surveillance test results of both emergency diesel generators, the
NRC team determined this performance deficiency was minor, in accordance
Enclosure
118
with IMC 0612, Appendix B, because it did not affect the Mitigating Systems
cornerstone objective of availability, reliability, or capability of the system.
.1 Design Change Not Appropriately Reviewed by Entergy
Introduction. The NRC team identified a preliminary greater than Green finding and
apparent violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control,
associated with Entergys failure to ensure that design changes were subject to
design control measures commensurate with those applied to the original design and
were approved by the designated responsible organization. Specifically, Entergy
received a new style right angle drive for the A emergency diesel generator radiator
blower fan from a vendor but failed to adequately review the differences between the
design of the original and replacement drive to identify potential new failure
mechanisms for the part or the need for related preventive measures.
Description. On September 28, 2016, while performing prestart checks on

emergency diesel generator X-107A, operations department personnel noted oil on
the deck and the oil level in the radiator fan gearbox below the vendors minimum
recommended level (11 pints). Additional checks identified that the pressure
setscrew on the oil relief valve for the gearbox had backed out which created a path
for oil to be lost. Emergency diesel generator X-107A was likely in this condition
since the completion of its last run on August 31, 2016, resulting in 28 days of
inoperability. Entergy initiated CR-PNP-2016-07443 to capture this issue in the
stations corrective action program. Entergy also documented an adverse condition
analysis in CR-PNP-2016-07443.
The NRC team reviewed the adverse condition analysis documented in CR-PNP-
2016-07443, and noted that Entergy had determined that this gearbox had been
installed in May 2000 as a like-for-like replacement for the original gearbox, and the
original gearbox did not have a relief valve in the oil circuit. Following the
September 28, 2016, discovery of this condition, Entergy determined that
approximately 2 pints of oil remained in the gearbox and 9 pints of oil had been lost
(minimum oil capacity specified by the vendor is 11 pints). Entergy attributed this low
oil condition to three causal factors: 1) a design limitation associated with minimal
thread engagement (1 2 threads) of the setscrew for the relief valve set pressure;
2) a potential for inadvertent operation of the setscrew; and 3) engine vibration
caused the setscrew to back out. However, Entergy was unable to determine which
of the identified causal factors was the most likely, therefore, they determined the
cause to be indeterminate. The NRC team questioned Entergys causal analysis,
and the adequacy of the May 2000 engineering evaluation performed for the
replacement gearbox.
With respect to the causal analysis, during discussions with Entergy, the NRC team
was informed that since every operator that may have gone into the room at some
point prior to this event could not be interviewed (all operators who entered the room
over the last sixteen years were not available), the station could not rule out
inadvertent manipulation of the setscrew and that was why Entergy determined that
the cause was indeterminate. The NRC team determined that this was not a valid
reason for classifying the cause as indeterminate. Specifically, the NRC team and
Enclosure
119
the resident staff had interviewed multiple operators about what is manipulated
during prestart checks of the emergency diesel generator and every operator who
was interviewed identified that the setscrew was not a component that is
manipulated. Based on the clear interview results, the NRC team determined that
the most likely cause of the setscrew backing out was vibration, and that the minimal
thread engagement was a contributing factor. This determination has been further
reinforced since following the NRC teams interviews, Entergy subsequently
interviewed all individuals who may have recently entered this space prior to the
event, and no one reported manipulating this component.
With respect to evaluations performed for the replacement gearbox, the NRC team
determined that in May 2000, while performing planned maintenance activities on the
A emergency diesel generator fan drive gearbox (right angle drive), Entergy
identified unsatisfactory backlash readings. This prompted Entergy to replace the
fan drive gearbox. While attempting to procure a replacement gearbox, it was
discovered that the vendor had upgraded the design and the model currently
installed was no longer available. Entergy determined that the major difference
between the models was that the new model incorporated a relief valve in the oil
circuit. Based on these discussions, Entergy determined that the new model
gearbox could be classified as a like-for-like replacement for the existing gearbox.
Entergy performed PDC/FRN 02-113, X-107A Emergency Diesel Generator
Radiator Fan Drive, Right Angle Gear Box Replacement, to document the like-for-
like evaluation for replacing the fan drive gearbox.
The NRC team also reviewed Station Procedure 3.02, Preparation, Review,
Verification, Approval, And Revision of Design Documents For Plant Design
Changes, Revision 38, and noted that Appendix A and B directed that for plant
design changes, design change packages were to be generated and these packages
were to be reviewed against the original design criteria by all groups responsible for
the original design.
The NRC team determined that Entergys characterization of the change as like-for-
like even though the new model incorporated a relief valve in the oil circuit was not
appropriate, and the replacement gearbox was, in fact, a design change. This
design change should have been subject to a review to determine the differences
between the new gearbox design and the old one to determine the suitability of
application of the part, and the failure to perform this review resulted in Entergys
failure to consider potential new failure mechanisms for the part or the need for
related preventive measures.
Analysis. Entergy selected a replacement gearbox for the A emergency diesel

generator in May 2000 without fully reviewing the differences between the new
gearbox design and the existing gearbox to determine the suitability of application of
the new part. Entergy characterized the change as like-for-like even though the
new model incorporated a relief valve in the oil circuit. As a result, Entergy did not
consider potential new failure mechanisms for the part, or the need for related
preventive maintenance activities, which was a performance deficiency. The
performance deficiency was more than minor because it was associated with the
design control attribute of Mitigating Systems cornerstone, and affected the
associated cornerstone objective to ensure availability, reliability, and capability of
systems that respond to initiating events to prevent undesirable consequences. In
Enclosure
120
accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 2 of

IMC 0609, Appendix A, The Significance Determination Process for Findings At-
Power, the team screened the finding for safety significance and determined that a
detailed risk evaluation was required based on the A emergency diesel generator
being inoperable for greater than the technical specification allowed outage time.
Region I senior reactor analysts performed a detailed risk evaluation. The finding
was preliminarily determined to be of greater than very low safety significance
(greater than Green). The risk important sequences were dominated by external fire
risk. Specifically, a postulated fire in the B 4KV switchgear room with a
consequential loss of the unit auxiliary generator power supply, non-recoverable
LOOP to both safety buses A5 and A6, loss of the B emergency diesel generator
with the conditional failure of the A emergency diesel generator, along with the loss
of bus A8 feed (from the shutdown transformer or SBO diesel generator) to safety
buses A5 and A6. The internal event risk was dominated by weather related LOOPs,
failure of the A emergency diesel generator, with failure of the B emergency diesel
generator and SBO diesel generator to run, along with failure to recover offsite power
or the emergency diesel generators. See Attachment 1, A Emergency Diesel
Generator Cooling Water System Degradation Detailed Risk Evaluation, for a
detailed review of the quantitative criteria considered in the preliminary risk
determination.
The NRC team did not assign a cross-cutting aspect to this finding because the
performance deficiency occurred in May 2000. Entergys program has undergone
changes since May 2000, and the NRC team did not identify any recent examples of
this performance deficiency. Other aspects of Entergys performance related to this
issue are further discussed in Sections 5.10.3 and 6.3.4.
Enforcement. 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires
that measures shall be established for the selection and review for suitability of
application of materials, parts, equipment, and processes that are essential to the
safety-related functions of structures, systems, and components to which Appendix B
applies (i.e., that prevent or mitigate the consequences of postulated accidents that
could cause undue risk to the health and safety of the public).
Technical Specification 3.5.F.1 requires that during any period when one emergency
diesel generator is inoperable, continued reactor operation is permissible only during
the succeeding 72 hours unless such emergency diesel generator is sooner made
operable, provided that all of the low pressure core and containment cooling systems
shall be operable, and the remaining emergency diesel generator shall be
operable. If this requirement cannot be met, an orderly shutdown shall be initiated
and the reactor shall be placed in the cold shutdown condition within 24 hours. The
72-hour limiting condition for operation can be extended to 14 days provided, in
addition to the above requirements, the SBO diesel generator is verified operable.
Contrary to the above, in May 2000, Entergy selected a part that was essential to the
safety-related function of a component to which Appendix B applies, and did not
review the part for suitability of application. Specifically, when Entergy replaced the
A emergency diesel generator radiator blower fan gearbox and discovered that the
installed model was no longer available, Entergy concluded that the new model could
be classified as a like-for-like replacement for the old one. However, the new
Enclosure
121
model incorporated a relief valve in the oil circuit that was not part of the installed
model and Entergy did not review this configuration for potential failure
mechanisms. Therefore, Entergy did not consider the need to periodically monitor or
maintain the part in this application. Consequently, Entergy also did not identify that
the relief valve had a design limitation associated with minimal thread engagement
(1-2 threads) of the setscrew for the relief valve set pressure. The technical
assumption is that as a result of gearbox pressurization and resultant forces applied
within the oil system and to the relief valve, over time, the setscrew backed out, and
Entergy, on September 28, 2016, identified that the gearbox had lost most of its oil,
and contained an amount that was below the minimum recommended level. This
resulted in the A emergency diesel generator being inoperable for a period greater
than the technical specification allowed outage time. This violation is being treated
as an apparent violation pending a final significance (enforcement) determination.
(AV 05000293/2016011-06, Design Change Not Appropriately Reviewed by
Entergy)
.2 Failure to Report Condition Prohibited by Technical Specifications and a Safety

System Functional Failure
Introduction. The NRC team identified a Severity Level IV non-cited violation of 10

CFR 50.73, Licensee Event Report System, associated with Entergys failure to
submit a licensee event report within 60 days following discovery of an event
meeting the reportability criteria. Specifically, on September 28, 2016, Entergy
identified the A emergency diesel generator was inoperable. The NRC team
determined this condition was prohibited by technical specifications and the
inoperability of the A emergency diesel generator existed for a period of time longer
than allowed by Technical Specification 3.5.F, Core and Containment Cooling
Systems. This was also reportable as a safety system functional failure.
Description. On September 28, 2016, operations declared the A emergency diesel

generator inoperable and entered Technical Specification 3.5.F, Core and
Containment Cooling Systems, in order to perform prestart checks on the diesel.
While performing the prestart checks prior to running the A emergency diesel
generator technical specification monthly surveillance, operators found oil on the
deck and the oil level in the radiator fan gearbox below the manufacturers minimum
recommended level (2 pints vice 11 pints). Additional checks identified that the set
screw on the oil relief valve for the gearbox had backed out which allowed oil to leak
out at some point during the prior operation of the emergency diesel generator on
August 30, 2016. Based on the as-found condition, operations determined that the
A emergency diesel generator would not be capable of running for its required
mission time (30 days). Entergy initiated CR-PNP-2016-07443 to capture the issue
in the stations corrective action program, and work order 457101 to correct the
identified condition.
Entergy subsequently performed a reportability evaluation and documented it in CR-

PNP-2016-07443. Entergy determined that the issue was not reportable because
the A emergency diesel generator was inoperable at the time of discovery, and the
low oil level had been corrected and the diesel returned to operable status within the
technical specification allowed outage time. Subsequently, on October 13, 2016,
Entergy initiated CR-PNP-2016-07899 to identify that the low oil condition
documented in CR-PNP-2016-07443 was a maintenance rule functional failure.
Enclosure
122
Entergy determined that the condition represented a maintenance rule functional

failure because the diesel could not perform its maintenance rule function for the
required mission time. This CR was not coded for further operability or reportability
review and was subsequently closed to CR-PNP-2016-07443.
While reviewing the adverse condition analysis documented in CR-PNP-2016-07443,

the NRC team determined that the A emergency diesel generator had been
inoperable since its prior surveillance run on August 30, 2016. Specifically, the NRC
team determined that due to the system configuration, with the relief valve above the
sump oil level, oil would only leak from the relief valve when the diesel was running.
This meant that the fan gearbox had been in a low oil level condition since the prior
surveillance run in August (29 days), and that the diesel had been inoperable for that
period of time as well. The NRC team noted that Technical Specification 3.5.F,
Core and Containment Cooling Systems, allows one emergency diesel generator to
be inoperable for 72 hours, extendable to 14 days if the SBO diesel generator is
verified to be operable. Based on this, the NRC team determined that the A
emergency diesel generator had been inoperable for longer than its technical
specification allowed outage time, and should have been reported under the
requirements of 10 CFR 50.73(a)(2)(i)(B).
On September 15, 2016, the B emergency diesel generator was inoperable for the
planned monthly operability run. During this time, both the A and B emergency
diesel generators were inoperable at the same time which is a condition that could
have prevented the fulfillment of the safety function of a system needed to shut down
the reactor and maintain it in a safe condition, remove residual heat, and mitigate the
consequences of an accident which is reportable in accordance with 10 CFR
50.73(a)(2)(v)(A), 50.73(a)(2)(v)(B), and 50.73(a)(2)(v)(D). The B emergency diesel
generator remained available.
The NRC team explained their conclusion to Entergy and Entergy agreed that the
issue should have been reported, and that the report was late. Entergy initiated CR-
PNP-2016-09552 to capture this issue in the stations corrective action program, and
on December 9, 2016, submitted Licensee Event Report PNPS-LER-2016-008.
Analysis. Entergys failure to submit a licensee event report within 60 days following
discovery of an event meeting the reportability criteria was a performance deficiency.
Because this performance deficiency had the potential to impact the NRCs ability to
perform its regulatory function, the NRC team evaluated the performance deficiency
using traditional enforcement. The violation was evaluated using Section 2.3.11 of
the NRC Enforcement Policy, because the failure to submit a required licensee event
report may impact the ability of the NRC to perform its regulatory oversight function.
In accordance with Section 6.9.d, Example 9, of the NRC Enforcement Policy, this
violation was determined to be a Severity Level IV non-cited violation. Because this
violation involves the traditional enforcement process and does not have an
underlying technical violation, the NRC team did not assign a cross-cutting aspect to
this violation, in accordance with IMC 0612, Appendix B.
Enforcement. 10 CFR 50.73(a)(1) requires, in part, that the licensee shall submit a
licensee event report for any event of the type described in this paragraph within 60
days after the discovery of the event. 10 CFR 50.73(a)(2)(i)(B) requires, in part, that
licensees shall report any operation or condition prohibited by the plants technical
Enclosure
123
specifications. 10 CFR 50. 73(a)(2)(v)(A), 50. 73(a)(2)(v)(B), and 50.73(a)(2)(v)(D)

requires, in part, that licensees shall report any event or condition that could have
prevented the fulfillment of the safety function of structures or systems that are
needed to shut down the reactor and maintain it in a safe shutdown condition;
remove residual heat; or mitigate the consequences of an accident. Contrary to the
above, Entergy failed to submit a licensee event report for an event of the type
described in this paragraph within 60 days following discovery of the event.
Specifically, from September 28, 2016, until December 9, 2016, Entergy failed to
make a required report when it was discovered that the A emergency diesel
generator was not operable, as required by station Technical Specification 3.5.F, and
on September 15, 2016, when both emergency diesel were inoperable resulting in a
safety system functional failure. Because this violation has been entered into the
corrective action program as CR-PNP-2016-09552, compliance was restored in a
reasonable amount of time, and the violation was not repetitive or willful, this Severity
Level IV violation is being treated as a non-cited violation, consistent with Section
2.3.2.a of the Enforcement Policy. (NCV 05000293/2016011-07, Failure to Report
Condition Prohibited by Technical Specifications and a Safety System
Functional Failure)
6.8 Emergency Preparedness Equipment and Facilities
The NRC team assessed emergency preparedness related equipment and facilities
against Emergency Plan commitments and reviewed the adequacy of the
surveillance program to maintain equipment and facilities. Specifically, through
interviews, tours, and sampling equipment lockers, the NRC team verified that onsite
and offsite emergency facilities were adequately maintained and supplied to be in a
state of readiness to implement the emergency plan. Surveillances of facilities,
communications systems, and notification equipment were checked for completion
and for the identification and correction of any identified problems.
The NRC team found the facilities and equipment to be in a state of readiness to
implement the Emergency Plan.
Prior to this inspection, Entergy had identified several instances in 2012 and 2015
when the H2O2 monitors and post-accident sampling system had been out of service
for extended periods of time thereby impacting the ability to implement emergency
action levels (EALs) for assessment of gas concentrations inside of containment.
Due to the other EALs, Entergy was able to make the appropriate emergency
declarations in an accurate and timely manner. Entergy determined that ineffective
troubleshooting, inadequate causal analysis, and inappropriate prioritization of
corrective measures resulted in these long-standing equipment issues and the failure
to maintain equipment reliability. Corrective actions included returning the H2O2 and
the post-accident sampling systems to Maintenance Rule 10 CFR 50.65 (a)(2) status
in May 2016 and updating EP-AD-270, Equipment Important to Emergency
Response, to identify necessary equipment and the associated compensatory
measures or equipment. A list of equipment important to emergency response was
added to the agenda to be reviewed by Entergy during the plan-of-the-day meetings.
Enclosure
124
Entergys corrective actions were effective in ensuring the capability to monitor and
assess containment gases.
The NRC team determined that this was a licensee-identified violation and
documented this issue in Section 9 of this report.
6.9 Engineering Programs Problem Area
During the IP 95003 Collective Evaluation process, a number of negative

observations were made regarding engineering programs in general. Specifically,
the evaluation determined that some engineering programs such as maintenance
rule, flow-accelerated corrosion, and preventive maintenance were not being
adequately implemented, and this resulted in long-standing equipment problems and
unacceptable material condition deficiencies, equipment failures, system
unavailability, and regulatory non-compliance. As a result, Entergy identified
engineering programs as a problem area and performed an apparent cause
evaluation in CR-PNP-2016-02061. The apparent cause evaluation documented the
following causes:
Apparent Cause: PNPS site engineering leadership did not provide adequate
oversight of engineering programs and programmatic processes.
Contributing Cause 1: PNPS organizational structure and capacity were not

adequate to ensure long term successful performance of engineering
programs and processes.
Contributing Cause 2: Implementation of corrective actions was insufficient

to return the programs to health.
Contributing Cause 3: Turnover of personnel has occurred with no change

management or succession planning.
Contributing Cause 4: PNPS has exhibited weaknesses in technical

conscience with inadequate recognition of risk.
Entergy identified the following key corrective actions in the corrective action plan:
CR-PNP-2016-02061 CA-14: Utilize a fleet subject matter expert who is an

industry expert in the areas of Maintenance Rule to provide mentorship and
coaching to station maintenance rule coordinator.
CR-PNP-2016-02061 CA-22: Add an annual training requirement (read and

sign) for conduct of engineers.
CR-PNP-2016-02061 CA-18: Roll out a new NRC Safety Culture Trait talk as
a weekly discussion at the engineering morning meeting.
Enclosure
125
CR-PNP-2016-02061 CA-20: Engineering director to issue a directive

requiring corrective actions be assigned to the supervisor with the sub-
response to the individual contributor and not directly to the individual
contributor.
CR-PNP-2016-02061 CA-21: Add an element to the yearly performance

review to require that supervisors, managers, and directors are accountable
for the health of the programs under their cognizance.
Entergys EFR for actions included in CR-PNP-2016-02061 was to perform

assessments of the PNPS engineering department in areas such as:
Equipment failures as a result of inadequate implementation of preventive

maintenance work orders on critical plant components and systems
Component failures of critical components included in the flow-accelerated

corrosion monitoring program
Incorrect maintenance rule functional failure determinations or incorrect

unavailability hour determinations by maintenance rule program personnel.
The NRC team performed a review of the engineering programs apparent cause
evaluation documented in CR-PNP-2016-02061, and associated corrective actions
planned and already implemented. The NRC team conducted interviews with key
personnel, including design and system engineers; performed field walkdowns to
visually inspect several safety-related systems and components to verify the material
condition of structures, systems, components, and support systems; attended
meetings associated with the plant health program; and performed a review of key
system health reports. In addition, the NRC team assessed preventive maintenance
scope, frequency, deferrals, technical bases, and use of vendor recommendations
and industry experience; and longstanding equipment issues. The NRC team also
assessed the extent of condition for design and licensing basis performance issues
and reviewed completed self-assessments in the preventive maintenance, flow
accelerated corrosion, and maintenance rule programs. Additionally, the NRC team
assessed the effectiveness of corrective actions for deficiencies identified by Entergy
involving engineering programs and assessed the operational performance of
selected safety systems to verify the capability of performing their intended safety
functions. The NRC team completed an assessment of a sample of PNPSs
engineering programs including:
Flow Accelerated Corrosion Monitoring Program

Maintenance Rule Program
Preventive Maintenance Program
Large Motor Program
Aging Management Programs
Single Point Vulnerability Review Program
Modification Program
Enclosure
126
The NRC team concluded that Entergys evaluation of the engineering program
issues documented in CR-PNP-2016-02061 was comprehensive. The evaluation
provided a critical look at engineering management oversight and mentoring, work
force resources, and outage schedule. The NRC team verified additional
engineering staffing has been added to maintain the appropriate level of program
engineering staffing to ensure safe and reliable operation of the plant until planned
permanent shutdown in 2019. In addition, adequate monitoring tools for detection of
corrective action program performance have been implemented. The NRC team
verified an adequate extent of condition review was also performed. In addition,
improved engineering support and management oversight of the plant material
condition and equipment performance were noted, including the implementation of
the new mentoring program with industry subject-matter experts to provide an
ongoing diagnostic assessment of plant performance and also that the EFRs have
been established for the CAPRs.
However, the NRC team identified several examples which indicated that
deficiencies in engineering programs and implementation of the corrective action
program continue to challenge the organization. The following specific issues related
to the area of engineering and engineering programs were identified during the
inspection, and are documented in Section 6.9.4 of this report:
The NRC team identified a finding associated with the failure to effectively
control and monitor the performance of maintenance rule scoped equipment.
The NRC team identified a finding associated with the failure to correct a
condition adverse to quality associated with non-safety-related floor grating in
contact with or in close proximity to the safety-related containment drywell
liner.
The NRC team identified a finding associated with the failure to take timely
corrective actions for a condition adverse to quality associated with gasket
leaks on the B residual heat removal heat exchanger.
.1 Failure to Adequately Monitor the Performance of Maintenance Rule Scoped

Components
Introduction. The NRC team identified a Green non-cited violation of 10 CFR

50.65(a)(2), Requirements for monitoring the effectiveness of maintenance at
nuclear power plants. Specifically, Entergy did not demonstrate that the
performance of 18 maintenance rule scoped components was effectively controlled
through the performance of appropriate preventive maintenance, and did not
establish goals and monitoring in accordance with 10 CFR 50.65(a)(1).
Description. In 2007, Entergy transitioned programs used to track and manage

preventive maintenance. During this transition, the 10 CFR 50.65(a)(2) performance
requirements for 18 components were inadvertently removed, and the components
Enclosure
127
were listed as run-to-failure. These components were required to be scoped into the
maintenance rule, as defined by 10 CFR 50.65(b), and be monitored either through
10 CFR 50.65(a)(1) goals or 10 CFR 50.65(a)(2) performance monitoring.
In CR-PNP-2016-07115, Entergy recognized these 18 components were incorrectly

listed as run-to-failure, and had been for the last nine years. However, Entergy did
not place these components into 10 CFR 50.65(a)(1) and establish goals and
monitoring when they identified the inability to demonstrate that the performance and
condition of the components was effectively controlled through preventive
maintenance. Instead, Entergy maintained the components in 10 CFR 50.65(a)(2)
status. Entergy determined that without component failures that resulted in
maintenance rule functional failures that caused the system or function to exceed the
established performance criteria, the components were correctly placed in 10 CFR
50.65(a)(2) status.
In accordance with the NRC Enforcement Manual, the 10 CFR 50.65 (a)(2)
performance demonstration must be technically justifiable and reasonable. When a
component is designated as run-to-failure, a technical evaluation should be done to
confirm that no maintenance or monitoring is required for that component under 10
CFR 50.65 (a)(2). Typically, this is to ensure the failure of the component would not
impact the systems ability to meet criteria found in 10 CFR 50.65 (b)(1) and (b)(2).
The determination that the run-to-failure designation is invalid makes the (a)(2)
performance demonstration for that system no longer technically justifiable.
Therefore the demonstration ceases to be valid and the structure, system, or
component is required to be moved to (a)(1). Upon identification of the concern,
Entergy had to develop a new performance demonstration for the 18 affected
components as documented in CR-PNP-2017-00401.
The NRC team determined that Entergy was not appropriately monitoring the 18
affected components to ensure that their performance or condition had been
demonstrated to be effectively controlled. The NRC team investigated the status of
the 18 components listed in CR-PNP-2016-07115 through a CR search and found
apparent examples of component failures that were treated as broke-fix and were not
captured and evaluated in the maintenance rule program to affirm the (a)(2)
performance demonstration remained valid.
Analysis. Entergys failure to effectively control and monitor the performance of

maintenance rule scoped equipment in accordance with 10 CFR 50.65(a)(2) was a
performance deficiency. The performance deficiency was more than minor because
it was associated with the equipment performance attribute of the Mitigating Systems
cornerstone and affected the cornerstone objective to ensure availability, reliability,
and capability of systems that respond to initiating events to prevent undesirable
consequences. Specifically, Entergy failed to demonstrate that the performance of
the 18 maintenance rule scoped components was being effectively controlled
through the performance of appropriate preventive maintenance, which adversely
impacts the reliability of those systems. The NRC team evaluated the finding using
Exhibit 2, Mitigating Systems Screening Questions, of IMC 0609, Appendix A,
Significance Determination Process for Findings At-Power, and determined this
finding did not affect the design or qualification of a mitigating structure, system, or
component; represent a loss of system and/or function; involve an actual loss of
function of at least a single train or two separate safety systems for greater than its
Enclosure
128
technical specification-allowed outage time; or represent an actual loss of function of

one or more non-technical specification trains of equipment designated as high
safety-significant. Therefore, the NRC team determined the finding was of very low
safety significance (Green). The finding had a cross-cutting aspect in the area of
Problem Identification and Resolution, Evaluation, in that Entergy failed to thoroughly
evaluate and ensure that resolution of the identified issue, maintenance not being
performed on maintenance rule scoped components, included reclassifying the
components as necessary. Specifically, Entergys failure to demonstrate that the
performance of 18 maintenance rule scoped components was effectively controlled
through the performance of appropriate preventive maintenance, necessitated the
need for a technically justifiable performance demonstration. [P.2].
Enforcement. 10 CFR 50.65(a)(1), requires, in part, that the licensee shall monitor
the performance or condition of structures, systems, or components within the scope
of the rule as defined by 10 CFR 50.65(b), against licensee-established goals in a
manner sufficient to provide reasonable assurance that these structures, systems, or
components are capable of fulfilling their intended functions. 10 CFR 50.65(a)(2)
states, in part, that monitoring as specified in 10 CFR 50.65(a)(1) is not required
where it has been demonstrated that the performance or condition of structures,
systems, or components is being effectively controlled through the performance of
appropriate preventive maintenance, such that the structures, systems, or
components remain capable of performing their intended function. Contrary to the
above, between 2007 and 2016, Entergy failed to demonstrate that the performance
of 18 maintenance rule scoped components was effectively controlled through the
performance of appropriate preventive maintenance, and did not establish goals and
monitoring in accordance with 10 CFR 50.65(a)(1). Entergys immediate corrective
action was to initiate a CR to evaluate moving the affected systems to 10 CFR
50.65(a)(1) monitoring requirements. Since this violation was of very low safety
significance (Green) and has been entered into the corrective action program as CR-
PNP-2017-00401, this violation is being treated as a non-cited violation consistent
with Section 2.3.2.a of the Enforcement Policy. (NCV 05000293/2016011-08,
Failure to Adequately Monitor the Performance of Maintenance Rule Scoped
Components)
.2 Ineffective Corrective Actions to Address Conditions Adverse to Quality Regarding

Components in Contact with or Close Proximity to the Drywell Liner
Introduction. The NRC team identified a Green non-cited violation of 10 CFR

Part 50, Appendix B, Criterion XVI, Corrective Action, associated with Entergys
failure to correct a condition adverse to quality affecting safety-related equipment.
Specifically, during a previous NRC inspection in August 2016, inspectors
identified numerous locations in the drywell where non-seismic equipment was
either in contact, or close proximity, with the drywell liner and had caused
damage. Entergy initiated CRs for the identified issues, and performed an
operability evaluation for the specific items identified by the inspectors, but failed
to take corrective actions to address the condition adverse to quality.
Description. Prior to the IP 95003 inspection, on August 22, 2016, during a

walkdown of the containment drywell while the plant was shutdown, the inspectors
performed visual inspections of the structural integrity of the reactor containment
drywell metal liner to verify the liner surface was free of defects, and to assess the
Enclosure
129
condition of the safety-related coatings inside containment. The inspectors also

reviewed controls of permanently installed equipment, structural supports, and
non-safety-related floor grating to protect the liner and the liner coatings from
damage. The inspectors identified that numerous sections of floor grating came in
direct contact or were in close proximity with the containment liner. In some cases,
contact by the floor grating had resulted in removal of the liner coating and/or minor
scratches. The inspectors also questioned several large structural safety-related
supports that were in close proximity to the liner. These issues created a potential
for liner damage during a design basis seismic event. Additionally, the inspectors
were concerned with the extent of this condition, since due to normal radiation-
related shine, several areas in containment were not accessible for the inspectors
to do a complete inspection of the liner. The inspectors also reviewed the last two
completed periodic coating inspections performed per procedure CEP-CII-003
during the last two refueling outages per American Society of Mechanical
Engineers (ASME) Section XI and noted that the minor damage to the containment
liner and coating caused by the floor grating had not been identified or
documented. To address the inspectors concerns, PNPS initiated CR-PNP-2016-
06188, CR-PNP-2016-06315, CR-PNP-2016-06242, and CR-PNP-2016-06316.
During the on-site inspection week of November 28, the NRC team performed a
follow-up review of Entergys operability evaluation and applicable corrective
actions documented in the four CRs and interviewed the system engineer and
engineering management personnel. The NRC team noted that Entergy engineers
determined there was no acceptance criteria established in any design drawings or
procedures to prevent interaction between structures, systems, and components
and the containment liner. The evaluation also determined the gouge caused to
the liner by the loose floor grating was only 0.008 inches deep and did not
challenge operability of the liner. Additionally, Entergy determined that the liner
damage potential was low due to the limited energy that could result in impact to
the liner during a design basis seismic event, the relative robust liner (1-1/16 thick
carbon steel plate) at the applicable elevations, and the thickness of the concrete
behind it. The NRC team noted that Entergy had implemented adequate corrective
actions to address only one of the conditions identified by the inspectors.
Specifically, per CR-PNP-2016-06242, actions were implemented to cut the floor
grating that was rubbing against a 1-inch stainless steel pipe associated with the
core spray loop break detection instrumentation. However, the NRC team noted
that Entergy had closed all four CRs without corrective actions to address the
condition adverse to quality identified by the inspectors regarding components in
contact with or close proximity to the drywell liner. Specifically, the NRC team
determined no actions had been implemented or planned to perform an extent of
condition review, to secure the loose grating that had caused the minor damage to
the liner, and to evaluate the need for a clearance criteria between components
such as floor grating and support structures and the containment liner to prevent
damage to the liner during normal plant operation and a postulated seismic event.
Although Entergy had determined there were no clearance requirements established

between the liner and components inside containment, the NRC team concluded the
seismic II/I classification delineated in PNPSs UFSAR was clear and the station
failed to consider this standard when making the decision to not implement any
actions to correct the condition adverse to quality identified by the inspectors.
Specifically, the NRC team noted that PNPS UFSAR Structural Design Section
Enclosure
130
12.2.1.1.2 states, in part, that Class II designated structures and/or equipment shall
not degrade the integrity of any structures and/or equipment designated Class I. Per
UFSAR Section 12.2.1.2, the PNPS drywell is a Class I structure. To accomplish the
objective above, UFSAR Section 12.2.3.5.1 continues to state that Class I to Class II
interfaces are designed so that there will be no functional failure in the Class I
structure. Entergy entered this issue into the corrective action program as CR-PNP-
2016-09346 and CR-PNP-2016-09377 to perform an extent of condition review, to
secure the loose grating, and to evaluate the need for a clearance criteria between
components such as floor grating and support structures and the containment liner.
Entergy also performed an operability determination that established a

reasonable expectation of operability pending implementation of corrective
actions. The NRC team reviewed the operability determination and agreed with
the conclusion.
Analysis. Failure to implement adequate corrective actions to address conditions

adverse to quality regarding components in contact with or close proximity to the
drywell liner constitutes a performance deficiency. The performance deficiency
was more than minor because it was associated with the configuration control
attribute of the Barrier Integrity cornerstone and affected the cornerstone
objective to provide reasonable assurance that physical design barriers (fuel
cladding, reactor coolant system, and containment) protect the public from
radionuclide releases caused by accidents or events. Using IMC 0609, Appendix
A, The Significance Determination Process for Findings At-Power, Exhibit 3,
Barrier Integrity Screening Questions, the NRC team determined that this
finding was of very low safety significance (Green) because the finding did not
represent an actual open pathway in the physical integrity of reactor containment
(valves, airlocks, etc.), containment isolation system (logic and instrumentation),
and heat removal components. This finding had a cross-cutting aspect in the
area of Problem Identification and Resolution, Evaluation, because engineering
evaluation of the degraded condition identified by the inspectors did not
thoroughly evaluate the containment liner issues to ensure that resolutions
address causes and extent of conditions commensurate with their safety
significance [P.2].

requires in part, that conditions adverse to quality such as deficiencies, deviations,
and non-conformances are properly identified and corrected. Contrary to the above,
from August 22 through November 28, 2016, PNPS failed to assure that conditions
adverse to quality were promptly identified and corrected. Specifically, PNPS failed
to address identified conditions adverse to quality regarding components in contact
with or close proximity to the drywell liner. As a result, no actions had been
implemented or planned to perform an extent of condition review, to secure the loose
grating that had caused minor damage to the liner, and to evaluate the need for a
clearance criteria between components such as floor grating and support structures
and the containment liner to prevent damage to the liner during normal plant operation
or a postulated seismic event. Entergy implemented immediate corrective actions to
enter this issue into the corrective action program for resolution. Entergy also
performed an operability determination that established a reasonable expectation of
operability pending implementation of corrective actions. Because this violation was
of very low safety significance (Green) and PNPS entered this issue into its corrective
Enclosure
131
action program as CR-PNP-2016-09346 and CR-PNP-2016-09377, this violation is

being treated as a non-cited violation, consistent with Section 2.3.2.a of the
Enforcement Policy. (NCV 05000293/2016011-09, Ineffective Corrective Actions
to Address Conditions Adverse to Quality Regarding Components in Contact
with or Close Proximity to the Drywell Liner)
.3 Failure to Promptly Correct a Condition Adverse to Quality for the Residual Heat
Removal System
50, Appendix B, Criterion XVI, Corrective Action, because Entergy did not take
timely corrective action for a previously identified condition adverse to quality.
Specifically, Entergy failed to adequately resolve gasket leakage on the B residual
heat removal heat exchanger, which resulted in continued degradation and leakage
for the heat exchanger gasket. Entergy did not consider this leakage or degraded
condition with the potential to impact the operability of the residual heat removal
system, or PNPS licensing basis with regards to leakage or a closed loop system
outside containment.
Description. On August 10, 2016, station personnel performed a visual inspection of

the B loop residual heat removal system suction and discharge piping. During this
inspection, a 90 drop per minute leak was identified on the B heat exchanger upper
flange with the system at test pressure. Entergy initiated CR-PNP-2016-05785 to
capture this issue in the stations corrective action program for resolution.
The NRC team reviewed Entergys response to CR-PNP-2016-05785 as part of the

inspection scope. During this review, the NRC team noted that Entergy had
classified the system as fully operable (no degraded condition exists) and closed the
CR to work order 51533968. The NRC team reviewed work order 51533968 and
noted that on August 16, 2016, the work order had been coded as returned with no
repair date scheduled. The NRC team questioned why Entergy had not classified
the leak as a degraded condition and did not appear to be planning a repair.
During subsequent discussions with plant staff, the NRC team learned that leakage
on the B residual heat removal heat exchanger was a long standing issue, and both
flanged joints (upper and lower) of the heat exchanger were identified as leaking.
The NRC team reviewed the history of this heat exchanger and determined that in
1979, the upper flange had been identified as leaking and Entergy had done leak
injection to stop the leak. In 1987, the upper flange was again found leaking and the
lower flange was also identified as leaking. Entergy again performed leak injection
to address the leaking joints. In 2007, the lower flange was again identified as
leaking (3 gallons per minute), and again, Entergy performed leak injection to
address the leakage. In May 2015, during piping inspections, station personnel
identified a 30 drop per minute leak on the lower flange. CR-PNP-2015-05378 was
written and closed to work order 00415067, which was subsequently closed on
April 12, 2016, with no work performed.
The NRC team determined that Entergy was not considering the leakage as a
degraded condition, and that Entergy was treating the leak injection activity as a
permanent repair. The NRC team noted that this was contrary to the NRC staffs
position documented in Part 9900 Technical Guidance Document, Online Leak
Enclosure
132
Sealing Guidelines for ASME Code Class 1 and 2 Components, dated July 15,
1997. Specifically, the staff identified the use of leak sealant as a temporary repair
option for leaking gaskets, and the leaking gaskets should be replaced at the next
refueling outage, or have a risk-informed deferral assessment.
The NRC team determined that Entergy had failed to take timely and adequate
corrective actions to correct the heat exchanger flange leakage issues on the B
residual heat removal heat exchanger or to perform a risk-informed deferral
assessment. The NRC team informed Entergy of their observations and Entergy
initiated CR-PNP-2016-09725 to capture this issue in the stations corrective action
program. Entergy also performed an operability determination that established a
reasonable expectation of operability pending implementation of corrective actions.
The NRC team reviewed the operability evaluation and agreed with the conclusions.
Analysis. Entergys failure to take timely and adequate corrective actions to correct a
condition adverse to quality, or to perform a risk-informed deferral assessment, was
a performance deficiency. The performance deficiency was more than minor
because it is associated with the equipment performance attribute of the Mitigating
Systems cornerstone and adversely affected the cornerstone objective to ensure
availability, reliability, and capability of systems that respond to initiating events to
prevent undesirable consequences. Specifically, the failure to correct identified
gasket leakage or to perform an appropriate evaluation of the condition resulted in
continued degradation and leakage of the heat exchanger gasket, and called into
question the operability of the heat exchanger. The NRC team evaluated the finding
using Exhibit 2, Mitigating Systems Screening Questions, of IMC 0609, Appendix A,
Significance Determination Process for Findings At-Power, and determined this
finding did not affect the design or qualification of a mitigating structure, system, or
component; represent a loss of system and/or function; involve an actual loss of
function of at least a single train or two separate safety systems for greater than its
technical specification-allowed outage time; or represent an actual loss of function of
one or more non-technical specification trains of equipment designated as high
safety-significant. Therefore, the NRC team determined the finding was of very low
safety significance (Green). The finding had a cross-cutting aspect in Human
Performance, Conservative Bias, because Entergy failed to use decision making
practices that emphasize prudent choices over those that are simply allowable
[H.14].

requires, in part, that measures shall be established to assure that conditions
adverse to quality are promptly identified and corrected. Contrary to the above, from
1979 through the present, Entergy failed to assure that conditions adverse to quality
were promptly identified and corrected without an engineering assessment of the
condition. Specifically, Entergy failed to adequately resolve gasket leakage issues
associated with the B residual heat removal system heat exchanger, which resulted
in continued degradation and leakage. Entergy implemented immediate correction
actions to enter this issue into the corrective action program for resolution. Entergy
also performed an operability determination that established a reasonable
expectation of operability pending implementation of corrective actions. Since this
violation was of very low safety significance (Green) and has been entered into the
corrective action program as CR-PNP-2016-09725, this violation is being treated as
a non-cited violation consistent with Section 2.3.2.a of the Enforcement Policy. (NCV
Enclosure
133
05000293/2016011-10, Failure to Promptly Correct a Condition Adverse to

Quality for the Residual Heat Removal System)
6.10 Preventive Maintenance Program
Entergy performed a review of components that are identified as the most risk
significant in the stations probabilistic risk analysis to identify any preventive
maintenance program deficiencies that could affect equipment reliability or potential
component aging issues that could challenge plant operations before the end of
operating plant life. In addition, on February 2, 2016, NIOS identified that the
Preventive Maintenance Oversight Group had not been effective at improving the
overall health of the preventive maintenance program to improve station equipment
reliability, and as a result, equipment failures continued to impact station safety and
reliability. Contributing to this was a Preventive Maintenance Oversight Group focus
on approving preventive maintenance deferrals instead of improving the
effectiveness of the preventive maintenance program and weak oversight by the
Plant Health Committee. The ineffectiveness of Preventive Maintenance Oversight
Group was determined as the apparent cause of not addressing preventive
maintenance program deferrals (CR-PNP-2015-08030). Entergy performed an
apparent cause evaluation under CR-PNP-2016-01273 to address these concerns.
The preventive maintenance evaluation documented that declining effectiveness of

the preventive maintenance program was the result of insufficient engineering
oversight to ensure longstanding program issues identified by external groups were
properly addressed. In addition, contributing causes such as personnel not being
knowledgeable about the preventive maintenance process and a lack of commitment
to program implementation were identified. Specifically, the assessment identified
poor engineering management oversight of issues that were identified in 2010, 2013,
and again in 2015 (CR-PNP-2015-08030 Preventive Maintenance Program
Deferrals) by external peer groups. Issues identified by Entergy included:
Managers deferred several critical preventive maintenance tasks and

removed them from the outage scope without full implementation of mitigation
strategies and prior to Preventive Maintenance Change Request-Action
Requests being approved.
Lack of preventive maintenance oversight and consistent standards

enforcement by the Preventive Maintenance Oversight Group has allowed
inadequate preparations and procedural adherence issues to continue
resulting in preventive maintenance deferrals.
Gaps in management of priorities and resource capacity during outage

periods led to preventive maintenance deferrals.
In addition, there were numerous instances where items were removed from outage
scope with little evidence that the risk of equipment failure was considered, or that
the risk was considered and tolerated. This decline in the preventive maintenance
program performance appears related to initiatives to reduce staffing. Specifically,
Enclosure
134
since 2006, PNPS has been a leader in workforce reduction efforts and has lowered
staffing by over 115 full-time equivalents.
The following corrective actions were identified under the preventive maintenance
assessment:
Assess the extent of condition in the preventive maintenance program.
Increase engineering resources to regain effectiveness in the equipment

reliability process.
Perform a preventive maintenance program self-assessment. This

assessment was started in August 2016 and identified the following key
issues:
- CR-PNP-2016-05871: A total of 653 components do not have criticality

classification documented
- CR-PNP-2016-07115: Eighteen high risk components are classified

Run-to-Failure and 11 components are classified as Non-Critical
- CR-PNP-2016-07243: Frequencies of preventive maintenance deviate

from preventive maintenance basis documents and Entergy preventive
maintenance templates
- CR-PNP-2016-07486: Preventive maintenance change request AR-

245704 technical justification to extend the frequency of 57 outage items
does not meet current industry or fleet standards
- CR-PNP-2016-07555: Risk significant components within the direct

current distribution system have no documented preventive maintenance
strategy within the basis documents
- CR-PNP-2016-07720: 4KV breakers and protective relays have duplicate

equipment numbers in the equipment database. The duplicate equipment
identifiers have contradictory criticality information
- CR-PNP-2016-08708: Risk-significant components, such as turbine

auxiliary oil pumps P-130A and P-130B, have preventive maintenance
actions scheduled years beyond the late date, and some preventive
maintenance actions have been closed without doing preventive
maintenance, due to motors considered not running although the motors
run monthly
The NRC team reviewed the preventive maintenance programs for the selected
systems to assess program adequacy and to determine whether design, vendor, and
generic information were appropriately incorporated into the maintenance program.
The NRC team did a sample review of operability evaluations for components whose
preventive maintenance strategy has either been deferred or had a frequency
Enclosure
135
change to beyond vendor recommended life of the components. Observations of in-

progress maintenance and testing on some systems were also conducted. The NRC
team reviewed Entergy procedure EN-DC-324, Preventive Maintenance Program,
and conducted interviews with PNPS personnel, including engineering personnel
who had an input into maintenance-related activities, to determine how the system
was operated, whether that operation conflicted with the intended safety function,
and whether engineering input was at an appropriate level to ensure safe and
reliable plant operation. The NRC team also assessed the application of the
preventive maintenance program to mitigate single point vulnerabilities, which
identified components whose failure can result in having to operate at reduced power
or a unit scram.
The NRC team also reviewed the following engineering program snap-shot self-
assessments performed by PNPS:
Check Valve Program (LO-PNPLO-2016-00054)

Air Operated Valve Program (LO-PNPLO-2016-00055)
Motor Operated Valve Program (LO-PNPLO-2016-00057)
Station Batteries Program (LO-PNPLO-2016-00061)
Large Motor Program (CR-PNPS-2016-2061, CA-99)
The NRC team assessed Entergys preventive maintenance program performance to

determine whether it was sufficient to support safe operation and whether planned
corrective actions would promote sustained performance improvement for the
remaining operating life of the plant. The NRC determined that Entergys evaluations
related to the preventive maintenance program were comprehensive. The
evaluations identified multiple conditions that contributed to the failure of the
preventive maintenance program to sustain reliable equipment performance.
Additionally, the stations evaluations identified multiple conditions that contributed to
the failure to identify and resolve declining performance. The NRC team concluded
Entergys evaluation was adequate and did not identify any significant additional
consequences from preventive maintenance scope reductions or those preventive
maintenance actions that had either been deferred or had a frequency change to
beyond vendor recommended life of the components.
6.11 Large Motor Program
The large motor program at PNPS is a long-term program to manage motors with
more than 200 horsepower. The intent is to identify, schedule, and track motor
rewinding and refurbishment. By procedure, this program is managed at the
corporate level with the PNPS program engineer responsible for monitoring and
maintaining the long range plan for motors onsite. From 2005 to 2006, the Entergy
Enclosure
136
fleet experienced several large motor failures as documented in CR-HQN-2007-

0972. In 2008, a fleet motor subject matter expert meeting determined that
continuous duty motors should have a time-based refurbishment and time-based
rewind tasks on a 16- and 30-year interval, respectively. It was recognized at that
time that some stations had motors beyond the 30-year time frame and that
availability of critical spares could further impede implementation. Based on Entergy
fleet operating experience, priority was given to continuous duty motors. In 2010,
actions were initiated to add preventive maintenance actions for refurbishments and
rewinds for continuous duty large motors. Any motors that were non-continuous duty
were not included as requiring time-based refurbishments. PNPS then experienced
several motor failures including:
In January 2012, the A residual heat removal pump motor failed (CR-PNP-
2012-00190). The fleet was consulted to add time-based preventive
maintenance for this non-continuous operating motor. The motor is in-service
when the train is selected for shutdown cooling during outages. The
preventive maintenance template was not changed.
In May 2013, the A turbine auxiliary oil motor failed (CR-PNP-2013-04190).

PNPS performed a root cause evaluation and implemented a time-based
strategy on non-continuous duty motors.
As corrective actions for these failures, PNPS initiated actions in December 2013 to
add a refurbishment task for five non-continuous duty safety-related motors: B, C,
and D residual heat removal pump motors and the A and B core spray pump
motors. Specifically, refurbishment of the B, C, and D residual heat removal
pump motors was set for 2017, 2019, and 2021, respectively. The core spray pump
motors were set for 2019 for A and 2021 for B. PNPS also determined that
continuous removal of large motors from the outage scope from 2011 to 2015 had
created a large backlog and put equipment reliability at an increased risk.
The NRC team performed a sample review of the large motor program and
associated corrective actions planned and already implemented. The NRC team
reviewed the list of large motor deferrals and associated risk reviews performed per
station procedure 1.3.142, PNPS Risk Review and Disposition. The NRC team
also conducted interviews with key personnel, including the motor program owner
and design and system engineers, performed field walkdowns to visually inspect
several safety-related motors and associated components to verify their material
condition, and reviewed applicable system health reports. The NRC team assessed
the maintenance, surveillance testing, and diagnostic activities of selected risk-
significant motors, including vibration, lubricating oil analysis, thermography
readings, Megger testing, and boroscopic inspections. The NRC team assessed
PNPSs implementation of online and outage maintenance, including backlogs;
preventive maintenance scope, frequency, deferrals, technical bases, and use of
vendor recommendations and industry experience; and longstanding equipment
issues. Additionally, the NRC team assessed the effectiveness of corrective actions
for deficiencies involving the selected motor performance and assessed the
operational performance of the motors and associated components to verify the
capability of performing their intended safety functions.
Enclosure
137
The NRC team also sampled the following mitigating strategies implemented by
PNPS to assess and evaluate applicable corrective actions regarding safety-related
or critical motors through the remaining operating life of the plant:
A reactor feedwater motor rewind (P-103A): This motor was refurbished in

August 20, 2013, but never rewound, and is not planned to be rewound for
the remaining operating life of the plant.
B reactor feedwater pump motor rewind (P-103B): Replacement with a

refurbished and rewound motor is scheduled for 1R21.
Circulating water pump motor rewind (P-105A): Rewind of this pump is not
planned to be completed for remaining operating life of the plant.
B, C, and D residual heat removal pump motor rewinds: Rewinds of these

pumps are not planned for the remaining operating life of the plant. An
available spare motor, which has been refurbished and rewound, is kept as a
ready spare for any of the motors, if needed.
The NRC team noted that deficiencies with the large motor program had been
properly captured by PNPS and that evaluations and some corrective actions had
been implemented or planned. Specifically, motor refurbishments and rewinds were
not being performed on some large motors.
The NRC team noted that PNPS had performed a risk evaluation per procedure
1.3.142 to remove the B residual heat removal pump motor from the scope of the
upcoming refueling outage (1R21) and keep the refurbished motor as a ready spare
for any of the motors, if needed. Additionally, as noted above, PNPS does not plan
on refurbishing or rewinding the C or D residual heat removal pump motors for the
remaining operating life of the plant. The NRC team questioned this decision since
these were the original motors that have been operating for almost 42 years without
a motor refurbishment or rewind. The NRC team reviewed PNPSs evaluation of the
A residual heat removal pump motor failure that occurred in 2012 (CR-PNP-2012-
00190); the motor was 40 years old when it failed. The NRC team noted that the
stations evaluation had determined the A motor winding failure was attributed to the
large number of motor starts. The number of starts on the A residual heat removal
pump motor was much larger when it failed than the number of starts for the other
three residual heat removal pump motors. This is because at PNPS, the A pump
has historically been the preferred pump for supporting shutdown cooling or other
activities. A review of the number of pump starts for a six-year period prior to 2012
identified the A pump had 302 starts, while the B pump only had 11 starts, the C
pump had 158 starts, and the D pump had 72 starts. The NRC team verified that
diagnostic test results for all four residual heat removal pump motors including
vibration, lubricating oil analysis, thermography readings, Megger testing, and
boroscopic inspections, are satisfactory and do not show any degrading trend. In
addition, yearly high voltage Baker testing performed on all four residual heat
removal pump motors since 2014 show satisfactory results. The NRC team noted
Enclosure
138
that PNPSs failure to properly implement the expected continuous duty and non-
continuous duty motors refurbishment and motor rewinds is a concern. However,
given the acceptable results in the predictive maintenance activities being performed,
the likelihood of failure of any of the safety-related motors that have not been
refurbished and/or rewound for the remaining three years of operating life of the plant
is low. Therefore, based on currently available data, and despite the deficiencies
identified by PNPS regarding their large motor program, the NRC team found no
significant issues or operability concerns.
6.12 Single Point Vulnerabilities
The NRC team assessed the application of the Preventive Maintenance Program to
mitigate single point vulnerabilities, which identified components whose failure can
result in having to operate at reduced power or a unit scram. PNPSs evaluation
documented a total of 342 components as single point vulnerabilities, and included
mitigation strategies in Single Point Vulnerability Unit Reliability Team 6-17-2013.
The NRC team interviewed the single point vulnerability program owner, reviewed
the current list of unmitigated single point vulnerabilities, and performed a sample
inspection of the safety review and operability evaluations for five currently
unmitigated single point vulnerabilities including PNPSs decision to not mitigate
(rewind) the A circulating water pump motor (P-105A) for the remaining operating
life of the plant. The NRC team also reviewed applicable large motor performance
monitoring data for these motors such as Megger test results, vibration data,
lubricating oil samples, and thermography readings. In addition, because industry
operating experience has identified age-related degradation of electrolytic capacitors,
the NRC team reviewed PNPSs assessments and applicable corrective actions for
several electrolytic capacitors with a 10- to 12-year recommended replacement cycle
that have never been replaced (i.e., greater than 41 years of operation). PNPS
determined these capacitors have a very high probability of failure due to aging and
obsolescence.
Capacitors are energy storage devices that are widely used in electronic and
electrical power circuits. Operating experience has shown that capacitors have finite
lifetimes. Placing these capacitors in a periodic preventive maintenance program
that accounts for both time in storage and time in service can address the adverse
effects of aging capacitors in equipment circuitry and prevent equipment failures.
EPRI TR-112175, Capacitor Application and Maintenance Guide, dated August
1999, states that capacitor change-outs are performed between 7 and 15 years
depending on vendor recommendations and plant operating experience. Another
EPRI document, Power Supply Maintenance and Application Guide (1003096),
dated December 2001, states that many of the power supplies that failed had been in
service greater than 15 years on average. The NRC team also reviewed PNPSs
shelf life program to ensure components that have a limited material life and
Enclosure
139
components containing limited shelf life materials that can suffer degradation of their
physical properties while in storage environment are properly addressed.
The NRC team sampled the following high critical single point vulnerability
assessments:
EC 5000071780, which modified the main turbine stator cooling runback logic
during 1R17 to eliminate an existing high critical single point vulnerability
Reactor feedwater pump motor rewind (P-103B), scheduled for 1R21
Circulating water pump motor rewind (P-105A), which will not be done for the
remainder of plant operating life
Start-up transformer X-4 rewind, scheduled for 1R21
Replace electrolytic capacitor for FIC-640-19A, feedwater regulating valve
FV-642A manual/auto control station, which was completed in 1R20
Replace electrolytic capacitor for FIC-640-19B, feedwater regulating valve
FV-642A manual/auto control station, scheduled for 1R21
Replace electrolytic capacitor for feedwater regulating valve FV-642A loss of
milliamp lock-up (UA-640-16A), scheduled for 1R21
Replace electrolytic capacitor for feedwater regulating valve FV-642B loss of
milliamp lock-up (UA-640-16B), scheduled for 1R21
Replace electrolytic capacitor for rod worth minimizer rod block (FA-640-
17A), scheduled for 1R21
Replace electrolytic capacitor for rod worth minimizer rod block (FA-640-
17B), scheduled for 1R21
Replace electrolytic capacitor for recirculation A & B run-back limiters
(LAHL-640-44A), scheduled for 1R21
Replace electrolytic capacitor for high water level feed pump trip, 2-out-of-2
logic (ALRM-640-44A), scheduled for 1R21
Replace electrolytic capacitor for high water level feed pump trip, 2-out-of-2
logic (ALRM-640-44B), scheduled for 1R21
Replace electrolytic capacitor for feedwater 1-element and 3-element control
computation module (640-51), scheduled for 1R21
Replace electrolytic capacitor for start-up feedwater regulating valve (640-
51), scheduled for 1R21
The NRC team verified that Entergy properly developed a list to identify and
establish mitigating strategies to reduce and resolve single point vulnerabilities. In
addition, the NRC team verified that the strategy and risk related to single point
vulnerabilities is communicated to management through several methods such as
the Preventive Maintenance Oversight Group, system health reports, and the Plant
Health Committee per Entergy procedure EN-DC-336. The NRC team noted that
Entergy has scheduled mitigation actions for most of the unmitigated single point
vulnerabilities for the upcoming refueling outage, 1R21. For the large motors, based
on current satisfactory equipment reliability trend data (Megger test results, vibration
data, lubricating oil samples, and thermography readings) and satisfactory
surveillance test results, the NRC team determined that Entergys decision to not
rewind the motors stated above was reasonable. The NRC team also noted that
Entergy has an action to perform a new comprehensive review of all capacitors by
Enclosure
140
the end of first quarter of 2017. For the currently unmitigated electrolytic capacitors,
the NRC team verified that visual inspections, cleaning, calibration, and test results
were satisfactory during the last refueling outage, 1R20. Since Entergy has
scheduled replacements for these capacitors during the next refueling outage, the
NRC team did not have an immediate operability concern.
6.13 Work Management Problem Area
Entergy identified that the preparation, control, and execution of work activities was
not rigorously implemented such that equipment reliability was the overriding priority.
Problems in the work management process resulted in high maintenance backlogs,
long-standing equipment reliability issues and deferred corrective actions. As a
result, Entergy identified work management as a problem area and conducted an
apparent cause evaluation under CR-PNP-2016-02057 to assess the issue. The
apparent cause evaluation documented the following causes:
Direct Cause: PNPS personnel do not consistently ensure all applicable

requirements of informational use procedures are identified and followed
when using informational use procedures.
Apparent Cause 1: Management did not always ensure that roles,

responsibilities, and expectations within the work management
process/program were clearly communicated, understood, and executed.
Contributing Cause 1: Some work management personnel do not always use

and adhere to the work management process procedures, specifically EN-
WM-100, Work Request Generation, Screening, and Classification, EN-
WM-101, On-Line Work Management Process, EN-WM-105, Planning,
and EN-WM-109, Scheduling.
Contributing Cause 2: Some work management coordinators lack in-depth

knowledge of the work management process.
Contributing Cause 3: Current staffing levels will not support reducing

backlog corrective/deficient and corrective action work orders and maintain
them within fleet and industry goals.
Though Entergys IP 95003 assessment teams did not specifically evaluate the work
management process, they did identify examples that point to process inefficiencies,
varying work group support of T-week requirements and resource issues that hinder
schedule execution.
Enclosure
141
Entergy implemented the following interim corrective actions:

CR-PNP-2016-02057 CAs-19 21, 25 28: Increase management oversight
and coaching for preparation activities such as work package or work task
walk downs and resource scheduling.
CR-PNP-2016-02057 CAs-29 35: Use an established burn down curve to

monitor the backlog reduction monthly through December 2016.
Entergy completed the following corrective actions:
CR-PNP-2016-02057 CA-36: Production Manager clearly outlines roles,

responsibilities, and expectations for conducting the work management
process.
CR-PNP-2016-02057 CA-39: Design, develop, and implement training for

work management coordinators to increase the process knowledge.
CR-PNP-2016-02057 CA-40: Validate the work order backlog so that

accurate planning and scheduling and backlog reduction can be
accomplished.
CR-PNP-2016-02057 CA-41: Increase fix-it-now team and maintenance

shop staffing to support reducing the work order backlog.
Entergys remaining corrective actions included:
CR-PNP-2016-02057 CA-42: Reassessing the staffing requirements in fix-it-

now team and the maintenance shops
CR-PNP-2016-02057 CA-37 38: Annually revisiting the roles,

responsibilities, and expectations for conducting the work management
process as outlined by the Production Manager.
The NRC team performed an assessment of the on-line work management process
and associated on-line risk assessment process. The review of the on-line work
management process encompassed the work planning and scheduling process for
T-weeks that directly impacted the on-line risk management. The review of the work
management process also covered the effectiveness of scheduling and
implementing work orders. The review covered both fleet and site-specific
procedures that defined roles, responsibilities, planning milestones, and
expectations.
To perform the review and assessment of the work management program, the NRC
team performed in-office document reviews, equipment walkdowns, attended
planning and scheduling meetings, observed the stations management of emergent
work, and interviewed work management personnel. Specifically, the NRC team
attended on-line work week planning and scheduling meetings designed to align
Enclosure
142
meeting objectives as defined in the procedures with meeting outcomes, noting

specifically preventive maintenance and surveillance due dates, allocation of work
hours coupled with required personnel, and management of work holds which
includes required materials and work order walkdowns. The NRC team also
reviewed post-work week critiques for 2016, held every week to evaluate the
stations adherence to the work week schedule, resource management, best
practices, and lessons learned.
The NRC team also reviewed Entergys actions to reduce high equipment backlogs,
and preventive maintenance practices regarding scheduling and frequency changes.
The NRC team noted that high equipment backlogs and emergent maintenance
activities had been impacting station resource loading and necessitating
rescheduling of some planned maintenance activities.
The NRC team noted that the work management program showed inconsistent
performance, as demonstrated from a sample of 2016 post-work week critique
reviews and CRs. From inspection activities and time onsite, the NRC team had the
following observations regarding the work management program and associated
implementation challenges:
Emergent work challenged the organization beyond what the Fix-it-Now team
was able to support, meaning that scheduled work was removed during the
work week and the associated resources were allocated for emergent work.
Procedurally identified work week milestones and completion criteria were not
aligned with work week meeting activities. Entergy moved work after the
schedule freeze, right up to the active work week, because the work was not
ready to be implemented. The work was not ready to be implemented for a
number of reasons, including: availability of workers, unavailable parts,
underestimated required work hours, or changed station risk profiles due to
the accommodation of emergent work.
Work management performance indicators that track the preparation of work

schedules were not consistent with the active work week scheduled and
approved work orders.
Work management meeting importance was inconsistently demonstrated

when the work week meetings are cancelled for emergent work or forced
outages and associated recovery efforts.
NIOS issued an elevation letter to the General Manager of Plant Operations

on May 2, 2016, regarding the ineffective work management program, and
the station responded by implementing corrective actions. The corrective
actions proved to be ineffective because NIOS proceeded to issue an
escalation letter to the Site Vice President, on October 18, 2016, regarding
the work management program, citing the same items as the elevation letter.
The NRC team was aligned with the concerns identified by NIOS and
Enclosure
143
observed the same behaviors and trends regarding schedule stability and
impact on equipment reliability.
The NRC team also determined that the work management program influenced
preventive maintenance. The NRC team reviewed Entergys practice of deferring
maintenance or changing the preventive maintenance frequency by extending time
between preventive maintenance activities. The NRC team determined that the
documentation supporting preventive maintenance frequency changes lacked
technical rigor and often credited the last as-found equipment condition being
satisfactory. Other preventive maintenance frequency change documents cite that
the preventive maintenance was not critical-path for refueling outages, and the
maintenance was removed from the outage scope, meaning production was
influencing preventive maintenance frequency changes. Changes to the preventive
maintenance program assessed by the NRC team have not been in place long
enough for the impact to be evaluated. (See Section 6.10 for additional discussion
on PNPSs preventive maintenance program.)
The NRC team concluded that the corrective actions implemented by Entergy were
marginally effective. Specifically, the PNPS work management program was
following procedural guidance, and was making progress to bundle related work,
correctly prioritize work, as shown by the reduced number of preventive maintenance
and surveillances in grace or deep grace, and relate required work hours to required
workers in the context of a full work schedule. However, PNPSs work management
program continued to struggle with emergent work, which is beyond the ability of Fix-
it-Now team to protect the planned work schedule, and required additional resources
to mitigate, as shown through post-work week critiques. Additionally, Entergy had
made little progress regarding the NIOS elevation and escalation letters, because
many of the concerns identified by NIOS continued to exist, as observed by the NRC
team. Overall, Entergy continued to struggle to implement the work management
process, and associated risk to effectively maintain the plant, as illustrated through
consistent emergent work.
No findings were identified. The NRC team determined that these work process
deficiencies impacted the efficiency of equipment performance improvements, but
did not result in any equipment inoperability or loss of function.
6.14 Industrial Safety Problem Area
Entergy identified that industrial safety behaviors at the station had been inadequate,
resulting in the Industrial Safety Performance Indicator remaining in the lowest
industry quartile for an extended period of time. Additionally, the Collective
Evaluation Team determined that, An increase in industrial safety events and station
personnel injuries is a precursor to a more significant event such as a serious injury,
fatality, catastrophic equipment failure, or degraded margin to nuclear safety. Past
corrective actions have not been effective to improve trends in industrial safety. As
such, Energy determined that industrial safety performance was a problem area and
Enclosure
144
performed an apparent cause evaluation to evaluate this area, as documented in

CR-PNP-2016-02062. This apparent cause evaluation documented the following:
Direct Cause: PNPS workers continue to have injuries that contribute to the
Total Industrial Safety Accident Rating indicator.
Apparent Cause 1: Station personnel at all levels have been ineffective in

recognizing situations that have risks normally associated with safety
behaviors, (i.e., poor situational awareness), for activities where they not are
closely monitored, observed, or coached.
Apparent Cause 2: Supervisors and managers have not enforced specific

safety behaviors practiced during routine activities outside of the power block.
Contributing Cause 1: Implementation of the corrective action program when

applied to industrial safety issues was ineffective with a resultant negative
impact on industrial safety.
Contributing Cause 2: In the past, the Area Safety Committee has been
ineffective due to limited participation and less than adequate procedural
guidance.
Entergy documented the following key corrective actions in the apparent cause
evaluation:
CR-PNP-2016-02062 CA-7: Develop and deploy an interactive computer

based training course that includes quizzes and has a pass/fail feature, to
include risk recognition and mitigation related to individual situational
awareness.
CR-PNP-2016-02062 CA-9: Develop and implement a dynamic learning

activity for risk recognition and mitigation to be presented to managers and
supervisors.
Though not specifically under the regulatory purview of the NRC, the NRC team
reviewed this apparent cause evaluation for any additional insights into PNPSs
recovery efforts and corrective action program implementation. The NRC team
assessed PNPS performance related to industrial safety to determine whether it was
sufficient to support safe operation and whether planned corrective actions would
promote sustained performance improvement. The NRC team conducted multiple
plant walkdowns and observed maintenance work in progress. The NRC team also
toured areas of the plant to assess the physical conditions, identify possible safety
hazards, and identify any deficiencies that had not been entered into the corrective
action program. The NRC team reviewed the apparent cause evaluation
documented in CR-PNP-2016-02062 to assess completion of corrective actions.
The report noted that past corrective actions have not been effective to improve
trends in industrial safety. The NRC team noted that all of the apparent cause
Enclosure
145
evaluation corrective actions were completed with the exception of CR-PNP-2016-

02062 CA-9, which is expected to be completed in the spring of 2017.
The NRC team verified during plant tours that safe work practices were employed
during observed maintenance work and no industrial safety hazards were identified.
The NRC team noted that there has been at least one significant industrial safety
incident at PNPS since completion of the apparent cause evaluation. An individual
was injured on October 26, 2016, while working at a location outside of the power
block. The individual required medical attention greater than first aid at a medical
provider, thus the injury was classified as an Occupational Safety and Health
Administration recordable injury. Entergy evaluated the event by non-adverse
analysis CR-PNP-2016-08273. All site personnel participated in a safety stand
down on November 1, 2016, to review a description of the event, why it happened,
immediate corrective actions, and lessons-learned. The NRC team reviewed the
non-adverse analysis evaluation and planned/completed corrective actions. The
NRC team also met with management from the affected department on December 5,
2016, to discuss the event and the effectiveness of the corrective actions to prevent
the same or similar industrial safety incidents. There are currently four open
corrective actions associated with this non-adverse analysis.
7. Safety Culture Assessment
7.1 Nuclear Safety Culture Fundamental Problem
PNPS identified that a significant contributor to declining performance at the station

was the failure of leaders to consistently demonstrate a commitment to emphasize
nuclear safety over competing goals. As such, the station identified nuclear safety
culture as a fundamental problem. PNPS completed an assessment of this
fundamental problem in root cause evaluation report CR-PNP-2016-02052, which
documented the following causes:
Direct Cause: PNPS priorities to address performance problems, emergent

equipment reliability issues, and change initiatives adversely impacted station
leaderships capability to maintain a strong nuclear safety culture. As a
result, the station experienced a decline in nuclear safety and regulatory
performance.
Root Cause: PNPS leaders have not held themselves and their subordinates
accountable to high standards of performance. This reduced the
effectiveness of the performance improvement/corrective action processes to
recognize and stop the decline in nuclear safety culture. As a consequence,
Enclosure
146
the station has experienced long-standing problems and increased regulatory

oversight.
Contributing Cause 1: Corporate leaders and independent oversight

organizations did not provide sufficient oversight of station performance to
ensure timely resolution of emerging, repetitive, and longstanding
performance problems. This contributed to performance gaps not being
resolved by the station.
Contributing Cause 2: Station leaders have not applied sufficient resource

management to support station priorities. Resources include personnel,
equipment and procedures. This contributed to increased station work
backlogs, and workloads which adversely impacted nuclear safety
performance.
PNPS implemented a number of key corrective actions to address the root and
contributing causes described above. Specific corrective actions included the
following:
CR-PNP-2016-02052 CAs-36, 37, 71 78: (CAPR-1A/1B) Utilizing the

guidance contained in EN-FAP-HR-006, Fleet Approach to Leadership
Development and Organizational Effectiveness, and EN-PL-100, Nuclear
Excellence Model, develop (CAPR-1A) and implement (CAPR-1B) individual
Targeted Performance Improvement Plans for each supervisor and above (up
to and including the Site Vice President), that includes actionable
improvement items with date triggers to improve leadership behavior gaps
identified.
CR-PNP-2016-02052 CA-38: (CAPR-1C) Conduct a closure review board

(per PNPS Recovery Procedure 1.3.145) to review all Targeted Performance
Improvement Plans after they have been closed by the one-up leader. The
closure review board will ensure that the Targeted Performance Improvement
Plans are appropriately closed with sufficient evidence that all the objectives
have been satisfied.
CR-PNP-2016-02052 CA-41: Reinforce Entergys Managerial Accountability

Model as stated in EN-PL-100, Attachment 3.2, to improve consistent
performance of managerial and individual accountability at all levels in the
organization. This is a one-time action that can be closed when use of
Entergys Managerial Accountability Model has been reinforced with 90
percent of the target population.
CR-PNP-2016-02052 CA-43: Develop a PNPS handbook (or equivalent)

based on the EN-PL-100 Nuclear Excellence Model (PNPSs vision, mission,
strategy, goals, core values, attributes of leader, and individual behaviors),
and site specific recovery procedure.
CR-PNP-2016-02052 CA-44: Conduct alignment sessions with station

leadership on the content and implementation expectations of EN-PL-100,
Nuclear Excellence Model, and PNPS employee handbook or equivalent.
Enclosure
147
These sessions will be led by the Site Vice President and focus on
establishing accountability for high standards of performance to align
behaviors in support of a strong nuclear safety culture.
CR-PNP-2016-02052 CA-45: Senior Managers to rollout the PNPS

employee handbook or equivalent to site personnel.
CR-PNP-2016-02052 CA-46: Revise the New Employee Onboarding

Checklist to include employee receiving a PNPS handbook and a discussion
by the manager on the PNPS handbook concepts and expectations for use.
CR-PNP-2016-02052 CA-47: Procure two external subject matter expert

resources as observation/coaching mentors for the station in establishing the
proper observation standards to station coaches in the field. This action will
remain in place until the end of first quarter 2017.
CR-PNP-2016-02052 CA-56: Establish and implement procedural guidance

for a workforce planning process to include development and implementation
guidance for a PNPS Integrated Strategic Workforce Plan that extends to the
end of plant operations and provides future staffing needs.
CR-PNP-2016-02052 CA-57: Develop and implement a procedure to

conduct a PNPS People Health Committee to place priority on staffing and
retention issues that are impacting PNPS employees.
CR-PNP-2016-02052 CA-60: Provide gap refresher Nuclear Safety Culture

training to improve station personnel including supervisors/managers,
knowledge and in-depth understanding of the attributes/traits of a healthy
nuclear safety culture and how nuclear safety culture influences nuclear
safety performance.
CR-PNP-2016-02052 CA-61: Establish a Nuclear Safety Culture Advocate

who will be an independent (external to Entergy) reviewer to monitor
leadership and individual accountability, as well as safety culture on a real-
time basis and report emergent concerns to the Site Vice President, Safety
Culture Leadership Team, Nuclear Safety Culture Monitoring Panel, and
specific departments to allow timely corrective actions. This position should
remain in place for the remainder of plant operations.
PNPS identified interim corrective actions to monitor the PNPS nuclear safety culture
until the corrective actions in CR-PNP-2016-02052 were accomplished and an EFR
was performed to ensure that the desired outcomes were achieved. Interim
corrective actions included:
CR-PNP-2016-02052 CA-62: Convene the Nuclear Safety Culture

Monitoring Panel on a frequency of no less than one meeting per month.
When necessary, convene the Nuclear Safety Culture Monitoring Panel to
address emergent issues or other matters of an imminent nature that, in the
judgment of the Chair, warrant immediate attention/action and should not be
deferred until the next monthly meeting.
Enclosure
148
CR-PNP-2016-02052 CA-31: Implement an emergent nuclear safety

culture issue process to allow the station to address safety culture issues that
appear to be safety conscious work environment related in a very timely
manner.
PNPS also identified the following EFRs to be performed:
PNPLO-2016-0085/1: Perform a baseline Leadership/Organizational

Effectiveness Survey and then perform the survey quarterly for one year to
measure leadership behavior effectiveness. The results are to be presented
relative to industry and/or plant norms. Success will be noted by a positive
trend of survey results demonstrating notable improvement within the first six
months and sustained performance the following six months would indicate
meaningful positive results. A notable improvement would equate to
approximately 50 percent of one standard deviation in the results.
PNPLO-2016-0085/2: Complete a nuclear safety culture assessment by an

independent external organization (similar to SYNERGY) that validates
improvements have been made in leadership, resources, and oversight of the
station. This review will be completed following completion of EFR-1 and will
include an interim assessment one year after CAPR-1B (Targeted
Performance Improvement Plans) is complete and another assessment one
year after the interim assessment is completed. A notable improvement
would equate to approximately 50 percent of one standard deviation in the
results.
PNPLO-2016-0085/3: Have a Leadership/Organizational Effectiveness

Survey completed that will measure leadership behavior effectiveness. A
notable improvement would equate to approximately 50 percent of one
standard deviation in the results.
PNPLO-2016-0085/4: Have a Leadership/Organizational Effectiveness

Survey completed that will measure leadership behavior effectiveness. A
notable improvement would equate to approximately 50 percent of one
standard deviation in the results.
PNPLO-2016-0086/1: Have a nuclear safety culture assessment completed

by an independent external organization (similar to SYNERGY) that validates
station.
PNPLO-2016-0086/2: Have a nuclear safety culture assessment completed

by an independent external organization (similar to SYNERGY) that validates
station.
Enclosure
149
The NRC team assessed nuclear safety culture to determine whether PNPS
practices supported safe operation and whether planned corrective actions promoted
sustained performance improvement.
In particular, the NRC team assessed actions to address nuclear safety culture
through a review of root cause evaluation CR-PNP-2016-02052. Attributes
considered in this review included the following: 1) whether the identification of
nuclear safety culture as a fundamental problem was appropriate, 2) whether the
identified direct, root, and contributing causes were appropriate, 3) whether the
corrective actions identified to address the direct, root, and contributing causes were
appropriate, 4) whether the corrective actions that have been implemented were
adequately implemented, 5) whether identified EFRs adequately assess the
effectiveness of the corrective actions, and 6) through independent performance-
based inspection, whether the overall problem was effectively addressed.
As part of the NRC teams overall assessment of nuclear safety culture as a

fundamental problem and the adequacy of PNPSs plans to address this
fundamental problem, the NRC team focused on the stations actions to address the
areas of standards and accountability and staffing adequacy. Additionally, because
a significant number of corrective actions had been completed by the end of this
inspection, the NRC team sampled these corrective actions to determine whether the
actions had been adequately implemented with quality.
The NRC team determined that the multi-year gradual performance decline occurred,
in part, due to declines in nuclear safety culture that went unrecognized and
unaddressed. Performance monitoring tools and management responses were
ineffective in recognizing and addressing the decline until they began to impact
performance. While nuclear safety remained a priority, actions to balance competing
priorities, manage problems, and prioritize workload resulted in reduced safety
margins.
The NRC team concluded that PNPSs nuclear safety culture evaluations were
comprehensive. The evaluation report documented multiple conditions that
contributed to the failure at the site and corporate level to identify and arrest
declining performance. The NRC team also concluded that the identified corrective
actions, if properly implemented, could be effective in addressing nuclear safety
cultures declines at PNPS. Specific observations related to PNPSs planned and/or
completed corrective actions are noted below:
Targeted Performance Improvement Plans
PNPS developed Targeted Performance Improvement Plans for all supervisors and
above, utilizing the guidance contained in EN-FAP-HR-006, Fleet Approach to
Leadership Development & Organizational Effectiveness, and EN-PL-100, Nuclear
Excellence Model. This action was designated as one of the CAPRs for this root
cause evaluation, with the other two CAPRs being implementation of the plans and
review of the completed plans by a closure review board.
Enclosure
150
The NRC team reviewed EN-FAP-OM-016, Performance Management Processes

and Practices, which included requirements for establishing Targeted Performance
Improvement Plans, and Attachment 7.3, Targeted Performance Improvement
Plan. The NRC team reviewed a sample of Targeted Performance Improvement
Plans that were generated for station leaders and determined that overall, these
plans included behaviors to be addressed, expectations and goals, required actions
to address the expectations and goals, and measurements that the expectations and
goals had been attained as specified in Attachment 7.3. In the Targeted
Performance Improvement Plans, Entergy identified three specific behavior problems
for first line supervisors and six specific behavior problems for managers and
directors, as summarized in the following table:
Managers First-Line
Gap
and Directors Supervisors
Leadership alignment and teamwork with peers X X
Effective communication, demonstration, and reinforcement
of the Excellence Model behaviors and standards to achieve
X X
ownership and accountability for performance by their
department personnel
Constructive coaching and mentoring to motivate and
X X
develop their employees
Effective monitoring and oversight of individual and team
performance to adjust talent, direction, leadership and X
resources as necessary for success
Strategic decision making practices that supports or affects
X
nuclear safety
Fostering a Learning Organization where employees use
self-assessment, benchmarking, operating experience and
X
the corrective action programs to recognize small signs of
decline and aggressively resolve performance gaps.
Overall, the NRC team concluded that although the Targeted Performance
Improvement Plans satisfied the requirements in EN-FAP-OM-016, the generic one-
size-fits-all approach, weak success criteria, and numerous administrative issues
suggested to the NRC team that further improvements could be realized and that in
the absence of these improvements, any performance improvement may not be
sustainable.
The following specific issues were identified to support this assessment:
Generic Targeted Performance Improvement Plans. The behavior problems

identified in the Targeted Performance Improvement Plans were generic in
nature and not intended to indicate that a particular supervisor specifically
exhibited the particular behavioral problem, but rather to ensure that the
specifically identified behavior problem was monitored through the Targeted
Performance Improvement Plan. These plans generally did not include any
other behaviors that could represent a specific nuclear safety culture
weakness for an individual. Similarly, the NRC team identified that the
actions to address the behaviors were frequently identical in nature, although
a more-tailored approach for each individual would likely include issues more
pertinent to improve the individuals performance. For example, one of the
Enclosure
151
generic actions was the performance of activities in the corrective action

program with quality and timeliness. The success measure for this action
was that All [corrective action program root and apparent causes] presented
to [the Corrective Action Review Board] will achieve a grade 3 or better.
During an observation of a monthly one-on-one meeting between the
Regulatory Affairs Manager and the Administrative Services Supervisor, the
NRC team identified that this generic Targeted Performance Improvement
Plan action and measure of success were included, although Administrative
Services were not typically involved with a root or apparent cause evaluation.
The NRC team discussed this specific action with the Regulatory Assurance
Manager, who subsequently revised the Targeted Performance Improvement
Plan to include more appropriate criteria for the individual.
Parallel Implementation of the Targeted Performance Improvement Plans. All

supervisors and above, including those in the same chain of command, were
placed on the same plans at the same time for the same behaviors. The
NRC team concluded that this called into question the effectiveness of the
coaching and implementation of the plans if all individuals were working on
the same gaps at the same time, versus sequencing implementation of the
plans such that a supervisor or manager would complete their requirements
prior to having to coach their subordinates.
Insufficient Duration for Improvement of Behaviors. Entergy procedure EN-

FAP-OM-016, Performance Management Processes and Practices, Section
3.2[6] notes that the timeline for a Targeted Performance Improvement Plan
should be between 30 90 days. Each plan noted that the individual was
supposed to meet with their manager every thirty days for a total of three
meetings. The original due date for completion of implementation of these
plans, and the associated closure review boards, was December 16, 2016.
This limited timeframe did not appear to be of sufficient duration to ensure a
sustainable change in the culture of management and leadership of the
organization.
Unchallenging Success Criteria. The NRC team identified that in some

cases, the success measures were not challenging. For example, the
measure of success in the behavior problem area of Coaching only required
that the supervisor coach one direct report or any person working at PNPS
once in a month. Additionally, the NRC team identified that the measures of
success frequently omitted any independent verification, but rather relied
solely upon information provided during the interview. The NRC team
concluded that an independent verification that actions had been
accomplished would better ensure that the actions had been accomplished to
the satisfaction of the individuals supervisor.
Administrative Issues. The NRC team identified numerous administrative

issues including incorrect names that suggested sections from other Targeted
Performance Improvement Plans had been cut and pasted without an
adequate review; future meetings pre-credited as having been performed
that had not yet been performed; and plans that were identified to be satisfied
and closed without all problems satisfactorily addressed. In addition, during
Enclosure
152
some interviews, supervisors were unaware that a Targeted Performance

Improvement Plan had been implemented to address their individual
performance. After discussing these issues with PNPS, the station
completed an audit of the plans (CR-PNP-2016-09736) and identified a
substantial number of issues, including cases in which required behaviors
were not listed to be addressed, one-on-one meetings that were not held as
required, numerous cases in which identified behavior gaps were not being
addressed, legibility issues, the absence of written comments by the
supervisor, and similar or identical comments from meeting to meeting.
Guidance Procedure for Targeted Performance Improvement Plans. The

NRC team reviewed Entergy procedure EN-FAP-HR-006, Fleet Approach to
Leadership Development & Organizational Effectiveness, which was
referenced in CAPR-1B as the guidance to be used when implementing the
Targeted Performance Improvement Plans. The NRC team determined that
this procedure did not contain adequate information related to effective
implementation of the plans. Additionally, PNPS did not involve the human
resources department in development or implementation of the plans, even
though EN-FAP-HR-006 stated that these actions should be coordinated with
human resources. This could have created a missed opportunity for the
station to self-identify the implementation issues described in the finding
associated with this issue.
The finding associated with this issue is discussed in Section 7.1.4 of this inspection
report.
Nuclear Safety Culture Advocate
PNPS implemented the nuclear safety culture observation process using an

external Nuclear Safety Culture Advocate, and CA-61 was closed on August 26,
2016. The implementing memorandum associated with this action prescribed the
creation of this position and the commitment to staff the position for the duration of
PNPS operation. The NRC team concluded that the scope and format of the
external nuclear safety culture observation process was an appropriate
improvement and accountability tool.
The NRC team met with the Nuclear Safety Culture Advocate to discuss the
implementation of the actions established in the position. The NRC team learned
that a number of the responsibilities outlined in the charter were not being
performed by the Nuclear Safety Culture Advocate, but instead were being
performed by the subject matter experts. In particular, the Nuclear Safety Culture
Advocate had delegated responsibilities for attending meetings and other
activities to personally monitor nuclear safety culture performance to the subject
matter experts. As a result, the Nuclear Safety Culture Advocate focused on
monitoring nuclear safety culture performance through a review of documents,
such as CRs, audits, evaluations, and inspections, and reviews and self-
assessments, which were used to develop weekly and monthly reports for the
Nuclear Safety Culture Monitoring Panel. The NRC team verified that between
the subject matter experts and the Nuclear Safety Culture Advocate, all of the
advocates responsibilities were being performed. As such, the NRC team
concluded that the use of subject matter experts to alleviate the Nuclear Safety
Enclosure
153
Culture Advocate of the duties and responsibilities identified in the Nuclear Safety
Culture Advocate charter met the intent of the charter. PNPS documented this
observation in CR-PNP-2016-09646.
The NRC team found that the Nuclear Safety Culture Advocate was working very
closely with the Nuclear Safety Culture Monitoring Panel. In particular, the NRC
team identified examples in which emergent issues identified by the Nuclear
Safety Culture Advocate were discussed at a special Nuclear Safety Culture
Monitoring Panel meeting, through which immediate actions were developed to
address the advocates concerns. The NRC team concluded that in general,
based on the interviews conducted, as well as the reports reviewed and Nuclear
Safety Culture Monitoring Panel meeting observed, that the Nuclear Safety
Culture Advocate role was being effectively implemented.
Subject Matter Experts
CR-PNP-2016-02052, CA-47 required that PNPS procure two external subject

matter expert resources as observation/coaching mentors to assist the station in
establishing the proper observation standards and act as Coach the Coaches. The
NRC team determined that PNPS hired multiple subject matter experts as a portion
of the overall station mentoring functions, as observation/coaching mentors. The
NRC team reviewed the resumes of a number of these subject matter experts and
determined that their background and experience supported their roles and
responsibilities as subject matter experts.
The NRC team reviewed the Project Plan for the subject matter experts and noted
that this plan included meetings, interviews, and field activities. The NRC team
reviewed the evaluation form used by the subject matter experts (i.e., WILL sheet),
and noted that it included nuclear safety culture standards to assess the activities.
The NRC team concluded that the evaluation form appeared to be a good tool to
ensure consistency and quality in the observation process.
The NRC team concluded that for the meetings observed, the subject matter
experts were actively engaged in assessing the conduct of the meeting. In
particular, the NRC team noted that at times, the subject matter experts generated
CRs when their concerns were not addressed by PNPS to their satisfaction. For
example, CR-PNP-2016-09147, dated November 18, 2016, documented that the
stations response had not been timely and conservative to address potential latent
equipment vulnerabilities that may exist due to inadequate maintenance strategies
on aging plant components.
However, the NRC team also observed that the subject matter experts routinely
exited the meeting without providing any direct feedback to those attending the
meeting, including the meeting leader. When interviewed, the subject matter
expert stated that feedback was typically provided to the meeting leader face-to-
face after the meeting to avoid providing criticism in the presence of peers and
subordinates. The NRC team considered this strategy and determined that some
immediate feedback to those in attendance, particularly to emphasize constructive
observations that reflected improvements, would be of benefit and should be
considered.
Enclosure
154
Additionally, during a Critical Evolution Meeting held on December 2, 2016, to

discuss performance of Procedure 8.M.2-2.10.8.5, Diesel Generator A Initiation
by Loss of Offsite Power Logic Critical Maintenance, the NRC team observed
that the subject matter expert asked questions of PNPS regarding the critical
activity being discussed before the meeting had been concluded. The NRC team
concluded that it would have been more appropriate for the subject matter expert
to ask questions after the meeting was concluded to be able to better assess
whether the questions asked by the subject matter expert would have otherwise
been asked by PNPS. This observation also led the NRC team to conclude that
the subject matter expert was not entirely external or independent of the process,
as intended.
The NRC team also reviewed a sample of the reports that documented the results
of the observations performed by the subject matter experts. The NRC team
concluded that these reports effectively presented the results of the subject matter
experts observations in a frank and open manner, such that lessons could be
learned and improvements realized. The NRC team also identified that the subject
matter experts had not yet begun to routinely perform in-field observations and
concluded that these observations were an important aspect of the PNPS
recovery.
Emergent Nuclear Safety Culture Issue Process
PNPS developed CR-PNP-2016-02052, CA-31 to implement an "emergent" nuclear

safety culture issue process to allow the station to address safety culture issues that
appeared to be safety conscious work environment-related in a very timely manner.
To address this action, PNPS utilized Entergy procedure EN-QV-136, Nuclear
Safety Culture Monitoring. The NRC team reviewed EN-QV-136 and confirmed that
Step 5.3[6](b) stated, in part, that emergent Nuclear Safety Culture Monitoring Panel
meetings may be called to take action on issues or concerns as necessary, and that
the Nuclear Safety Culture Monitoring Panel ensures that emergent issues with the
potential to impact the site nuclear safety culture health are brought to the attention
of the Safety Culture Leadership Team. The NRC team identified one example in
which an emergent issue with the potential to impact nuclear safety culture had been
brought to the attention of the Safety Culture Leadership Team through the
corrective action process, and dispositioned in an emergent Nuclear Safety Culture
Monitoring Panel meeting. The NRC team concluded that this corrective action was
appropriately closed.
Communications Plan Implementation
CR-PNP-2016-02052, CA-35 required that PNPS implement a communications plan

for all full-time site personnel and supplemental personnel that will allow PNPS to
more fully inform station personnel regarding the traits of a healthy nuclear safety
culture and how nuclear safety culture influences nuclear safety performance. The
intent of this action was to improve communications on nuclear safety culture and IP
95003 recovery issues and actions to improve safety performance. Additionally, CA-
35 was documented as a one-time interim action that could be closed when 90
percent of the target population received the communication.
Enclosure
155
The NRC team reviewed the documentation for CA-35 that was closed on
September 30, 2016. In their closure response, PNPS identified that on
September 26, 2016, a PNPS all-hands meeting was conducted to address this
corrective action and that all aspects of the corrective action were addressed at the
meeting. The closure response also indicated that the presentation was video
recorded to ensure any personnel who were unable to attend the meeting in person
had the opportunity to watch it at a later date; and that the presentation was posted
on the PNPS home page. The Recovery Manager reviewed the presentation and
response, and determined they were adequate.
The NRC team reviewed the CA-35 closure and identified that no objective evidence
was included in the closure documentation that demonstrated that 90 percent of the
target population had received the communication and that the target population
referenced in the corrective action was not defined. Subsequently, the NRC team
determined that the Action Closure Review Board had previously identified that
PNPS failed to provide documented evidence that 90 percent of the targeted
population had received the communications. To address this issue, PNPS revised
the corrective action to align with what had been accomplished. In particular, PNPS
senior management recommended that the corrective action be revised to require
that the presentation be made in person to the target population (Entergy PNPS
Employees) in an all-hands setting vice the original requirement of 90 percent of the
target population, and that the large attendance for the September 26, 2016, all-
hands meeting met the intent for a majority of the station population. This was
considered a change to the intent of the corrective action by PNPS. The NRC team
reviewed the basis for this change and identified that PNPS considered the action as
it was originally written to not be realistic or necessary. Following this change, the
Action Closure Review Board approved the closure of the corrective action.
The NRC team reviewed this action and concluded that the relatively small number
of employees that received the training, estimated to be less than 50 percent of
PNPS employees, adversely impacted the effectiveness of the corrective action.
The NRC team was also concerned that the target population did not specifically
include contractors and other supplemental workers involved in the day-to-day
operation of PNPS. The NRC team also concluded that redundancy and defense-in-
depth provided by other more substantive corrective actions, such as the gap
refresher training accomplished in CR-PNP-2016-2052 CA-60, mitigated the
significance of this issue.
PNPS Handbooks
CR-PNP-2016-02052 CA-43 through CA-45 required creation of a PNPS handbook

(CA-43), conduct of alignment sessions with station leadership on the content and
implementation expectations on the handbook (CA-44), and rollout of the handbook
to site personnel (CA-45). Additionally, CA-45 specified that the action could be
closed when signed acknowledgement was received from 90 percent of the target
population.
The NRC team reviewed the PNPS handbook, Building Our Legacy of Excellence,
and verified that all required elements were included, and that an alignment session
with station leadership was conducted. Receipt of the handbook by station
management was confirmed by signature. In the review of CA-44, the NRC team
identified that not all supervisors were required to receive the training since some
Enclosure
156
were assumed to have been unavailable at the time it was provided. The NRC team
questioned this standard since there was nothing in place to preclude the training
from being provided after the supervisor returned to the site. PNPS documented this
In addition, during the review of CR-PNP-2016-02052, CA-45, the NRC team

identified that no objective evidence was identified that demonstrated that 90 percent
of the target population had signed acknowledgement of the training, as required in
CA-45. Subsequently, the NRC team determined that the Action Closure Review
Board previously identified that PNPS failed to provide documented evidence that 90
percent of the target population had signed acknowledgement of the training. Similar
to the discussion of CR-PNP-2016-2052, CA-35, the NRC team determined that the
corrective action was subsequently revised. In this case, the corrective action was
revised and closed to reference CA-43, with the September 20, 2016, presentation
as objective evidence that the PNPS handbook was distributed.
The NRC team reviewed this action and concluded that the strength of the overall
corrective action effectiveness was adversely impacted by the change and that it was
not clear if all employees had received and were aware of the content of the PNPS
Employee Handbook.
Quarterly Leadership/Organizational Effectiveness Survey
One of the performance monitoring tools included in PNPSs Comprehensive

Recovery Plan to evaluate the effectiveness of safety culture improvement initiatives
was to conduct periodic surveys (CR-PNP-2016-02052, CA-40). The original due
date for this corrective action was August 31, 2016, and at the time of this inspection,
had been extended five times with a revised current due date of January 29, 2017.
The NRC team reviewed the first quarterly safety culture survey conducted by
Midwest Organizational Services LLC, dated December 4, 2016. This survey was
conducted with the intent of validating that improvements have been made in
leadership, resources, and oversight of the station. The NRC team identified several
inconsistencies between the survey, the Third Party Nuclear Safety Culture
Assessment, and the observations from the focus group interviews. For example,
the survey did not identify the security organization as needing additional
improvement in the area of resources. However, security had been identified by
Entergy as needing additional focus in this area, and the NRC team also identified
resources, specifically in security, as a challenge area during interviews with site
personnel. Members of the NRC team observed a meeting between the Nuclear
Safety Culture Advocate, the Performance Area Owner for Nuclear Safety Culture,
and the Assistant to the Site Vice President for the purpose of discussing the
effectiveness of the survey tool. The champions identified many of the same issues
with the survey that the NRC team did, and elected to discontinue use of this
particular quarterly survey tool. At the end of this inspection, the station was
evaluating an alternative method to assess the effectiveness of the corrective actions
(CR-PNP-2017-00169).
Staffing Adequacy
Root cause evaluation CR-PNP-2016-02052 documented that plant performance

declines, were exacerbated in June 2013 by the cumulative impact of initiatives to
Enclosure
157
reduce station staffing that occurred without sufficient change management which
placed additional demands on the workforce, and station performance continued to
decline in 2013 and was further impacted by the 2013 Human Capital Management
initiative as noted by Contributing Cause 2 of this report. Root cause evaluation
CR-PNP-2016-02052 also noted that the staffing at PNPS from 2006 to 2014 had
decreased by more than 115 full-time equivalents as compared to the average small
boiling water reactor staffing; and that the deviation was over 50 full-time equivalents
when compared to the median. Additionally, this root cause evaluation documented
that a Nuclear Human Capital Management Change Management Plan for
Implementation activity was drafted in response to the 2013 Human Capital
Management initiative, but was never implemented. The NRC team also noted that
resource issues were identified in other cause evaluations conducted as part of
PNPSs recovery evaluations, including those related to the work management (CR-
PNP-2016-02057), engineering programs (CR-PNP-2016-02061), and equipment
reliability (CR-PNP-2016-02056) problem areas.
To address this issue, root cause evaluation CR-PNP-2016-02052 identified that

corrective actions had been created to establish and implement procedural guidance
for an Integrated Strategic Workforce Plan to ensure the appropriate level of staffing
was maintained to support station goals and objectives (CA-56). Although this
corrective action remained open at the end of the on-site inspection weeks, the NRC
team discussed the action with PNPS and identified that the overall intent of the
action was to determine the appropriate level of staffing for safe and reliable
operation of PNPS. The Integrated Strategic Workforce Plan was expected to be
updated annually and reviewed at least twice per year by the PNPS People Health
Committee, and expected to include performance metrics and reviews, as delineated
in the process. Key departments, at a minimum, to develop and maintain the PNPS
Integrated Strategic Workforce Plan include: Operations, Radiation Protection,
Chemistry, Maintenance, Engineering, Training, Nuclear Independent Oversight,
Security, Emergency Planning, Performance Improvement, and Regulatory
Affairs/Licensing. The NRC team reviewed this plan and determined that, if properly
implemented, it had the potential to be an effective tool for workforce planning.
In addition to the Integrated Strategic Workforce Plan, root cause evaluation CR-
PNP-2016-02052 indicated that a separate procedure established a PNPS People
Health Committee (CA-57) to manage staffing and retention of personnel at the
department level. The NRC team reviewed the subject action, which was closed on
October 13, 2016, and noted that this activity was included as part of Procedure
1.3.145, PNPS Recovery Procedure, which was designed to capture specific high-
priority actions associated with PNPSs recovery. This particular action was one of
five actions in the nuclear safety culture area that were identified as high priority
actions at PNPS.
During this inspection, PNPS began implementing the PNPS People Health
Committee program. The resident inspectors observed the first PNPS People Health
Committee meeting that was held on December 16, 2016. In addition, the NRC team
reviewed the presentation and other materials used to introduce the committee
strategy to the PNPS People Health Committee team members. Based on the NRC
teams review of the materials presented at the meeting, including the strategies
being pursued at PNPS, as well as the observations by the resident inspectors who
attended the first committee meeting, the NRC team concluded that, if implemented
Enclosure
158
properly, the PNPS People Health Committee had the potential to provide an
adequate means to manage and address staffing and retention issues at PNPS.
The NRC team also reviewed some staffing-related corrective actions developed
from the results of the 2016 Third Party Nuclear Safety Culture Assessment, as
documented in CR-PNP-2016-04261. For example, CAs-30/33/36 required that
PNPS review mechanical maintenance staffing to ensure that the station maintains
the desired staffing levels, and initiate enhancements as needed. The NRC team
reviewed the subject actions, which documented that six to twelve months prior to
this survey, mechanical maintenance staffing levels were below desired levels due to
a variety of reasons. The corrective action also documented that as of August 1,
2016, mechanical maintenance staffing levels had fully recovered and that all
positions were fully staffed. As of October 13, 2016, when the action was closed, all
mechanical maintenance department positions remained filled. The NRC team
reviewed the subject package and verified that when the corrective action was
closed, all mechanical maintenance department positions were filled.
The NRC team also reviewed CR-PNP-2016-04261, CA-39, which required that the
station develop an organizational capacity matrix meter to be able to determine
impacts on staffing levels real-time to ensure staffing requirements were acceptable
to support work at PNPS. The matrix was designed to be a predictor for the
organization as a capacity measure using factors such as: 1) Backlogs, 2) Overtime,
3) Corrective Action Extensions, 4) Surveys, 5) Resignations, and 6) Attrition.
Although this action remained open with a due date of February 28, 2017, at the end
of the on-site inspection weeks, the NRC team determined that PNPS had planned
to integrate this action with CR-PNP-2016-02052, CA-56 to develop a process to
predict organizational capacity that could be used as an input into decisions made by
the PNPS People Health Committee. The NRC team reviewed this plan and
determined that, if properly implemented, it had the potential to be an effective tool
for workforce planning.
Staffing Benchmarking Assessment
To assess the overall staffing levels at PNPS, a benchmarking assessment was

performed which compared the nominal number of employees at sites similar in
design and operation with those at PNPS. This study, which was completed by a
contractor in the spring of 2016, documented that overall staffing levels at PNPS
were 19.8 percent lower than those at the three similar sites that were benchmarked.
During a discussion with PNPS management concerning these results, the NRC
team learned that this information had not been shared with plant management until
the study results had been requested by the NRC team to support this IP 95003
inspection.
Nuclear Sustainability Plan
During discussions of future staffing plans, as well as a review of a number planned

corrective actions [CR-PNP-2016-02052, CA-69; CR-PNP-2016-02054 (Decision-
Making/Risk Recognition), CA-47; and CR-PNP-2016-02056 (Equipment Reliability)
CA-61], the NRC team became aware of a future Entergy initiative referred to as the
Nuclear Sustainability Plan.
Enclosure
159
The Nuclear Sustainability Plan, which has been reviewed and approved by the
Entergy Board of Directors, focused on the following areas and initiatives:
Be Professional (People)
- Structure organization to support operational excellence
- Cultivate excellence in Nuclear Professional Behavior and Safety
Culture
- Train and develop people

- Support the company
Fix the Plant (Plant)

- Identify and eliminate equipment vulnerabilities
- Strengthen Fleet Technical Conscience
- Fortify Integrated Risk Management
Operate as a Fleet (Process)

- Align organization to a shared vision
- Strengthen corporate structure and capacity
- Create consistency through Peer Group improvements and ownership
- Improve strategic planning
According to Entergy management, these initiatives, such as structure the

organization to support operational excellence, were anticipated to result in a
significant increase in staffing and address a number of behavior gaps, including the
following:
Ensure that corporate leaders are holding themselves and their subordinates
accountable to high standards of performance and effectively use
performance improvement/corrective action processes to recognize and stop
the decline in nuclear safety culture, radiological, and industrial safety
performance
Ensure that corporate leaders, independent oversight organizations, and

other fleet station senior leaders are providing sufficient oversight of PNPS
and fleet performance
Ensure that corporate leaders are applying sufficient resource management

to support station and nuclear safety culture priorities
Ensure that resources are routinely evaluated to ensure plant operation and
equipment reliability are not adversely impacted
Ensure that strong teamwork and accountability between Corporate and the
station, and between station organizations is fostered and reinforced
At the end of the on-site weeks of this inspection, the Nuclear Sustainability Plan had
not yet been implemented. As of April 20, 2017, the NRC team had been informed
that the Nuclear Sustainability Plan had been renamed the Nuclear Strategic Plan.
Enclosure
160
PNPS has stated that several of the initiatives, such as Pilgrim People Health
Committee and Integrated Strategic Workforce Planning, have been fully
implemented. There were various other initiatives that PNPS planned to adopt such
as Recruitment Support, Operator Fundamentals, Nuclear Safety Culture Training
and Assistance, and a new Nuclear Excellence Model.
Failure to Adequately Develop and Implement Targeted Performance Improvement

Plans
Introduction. The NRC team identified a Green finding because Entergy did not
adequately develop and implement a CAPR of a root cause related to a Category A
CR, as required by Entergy procedure EN-LI-102, Corrective Action Program.
Specifically, Entergy did not adequately develop and implement the Targeted
Performance Improvement Plans, which were designated as a CAPR for the root
cause for the Nuclear Safety Culture Fundamental Problem.
Description. During performance of the Collective Evaluation process, PNPS

identified nuclear safety culture as a fundamental problem, and documented the
issue in CR-PNP-2016-02052. The station screened this CR as Category A, and
performed a root cause evaluation to further assess the issue. Entergy procedure
EN-LI-102, Corrective Action Program, Attachment 9.1 states, in part, that all
Category A CRs are investigated with a root cause report, and CAPRs are
developed. EN-LI-102, Section 3.0[9] also states that a CAPR is a type of corrective
action intended to eliminate or mitigate the root cause(s) of a condition, and thereby
preclude repetition. Additionally, Entergy procedure EN-LI-118, Cause Evaluation
Process, Section 5.6[11], states, in part, that CAPRs should eliminate the causes of
the significant event so that the same or similar events are not repeated, and clearly
result in long-term correction and be sustainable.
To address the identified root cause, the station developed three CAPRs, which
included development and implementation of Targeted Performance Improvement
Plans to address identified leadership behavior gaps, as well as conduct of a Closure
Review Board to ensure that the Targeted Performance Improvement Plans were
appropriately closed with sufficient evidence that the plan objectives were satisfied.
(Refer to Section 7.1.1 of this report for a more detailed discussion of the
root/contributing causes and CAPRs).
In some cases, the NRC team was not able to clearly link the causal factors
identified in root cause evaluation CR-PNP-2016-02052 to the CAPRs. For example,
in Attachment 8 of the root cause evaluation, PNPS determined that Causal Factor 2,
Insufficient Performance Monitoring, related to the root cause. Causal Factor 2
includes Failure to recognize declining performance (insufficient use of self-
assessment, benchmarking, operating experience, and performance indicators).
Per CR-PNP-2016-02052, a causal factor is an action or lack of action associated
with a problem statement that, if corrected, could have prevented the inappropriate
leadership behaviors from occurring or would have significantly mitigated their
consequences. In this case, though PNPS determined that Causal Factor 2 was
related to the root cause, the NRC team could not conclude that the CAPRs directly
addressed this causal factor. Specifically, the behavior gaps in the Targeted
Performance Improvement Plans that PNPS had developed to address this issue
Enclosure
161
were Fostering a Learning Organization where employees use self-assessment,

benchmarking, operating experience, and the corrective action programs to
recognize small signs of decline and aggressively resolve performance gaps and
Effective monitoring and oversight of individual and team performance to adjust
talent, direction, leadership and resources as necessary for success. The NRC
team determined that these behaviors were too broad to ensure the specific causal
factors were addressed to preclude repetition of similar problems.
The NRC team also reviewed a sample of Targeted Performance Improvement

Plans across multiple departments, including the actions identified to address
specific behavioral problems. The NRC team determined that there were multiple
significant weaknesses associated with PNPSs implementation of these plans.
Examples of implementation weaknesses identified by the NRC team include parallel
implementation of the plans, insufficient duration of corrective actions to improve
behaviors, generic versus specific counseling to address adverse behaviors, success
criteria that would not be expected to result in substantial performance improvement
at the station, and a large number of administrative issues. (Refer to Section 7.1.3 of
this report for a more detailed discussion of each of these weaknesses). The NRC
team determined that these significant implementation weaknesses severely limited
the overall effectiveness of the CAPR. Entergy documented this issue in the
corrective action program as CR-PNP-2017-00406.
Analysis. The NRC team determined that Entergys failure to adequately develop
and implement a CAPR to address a root cause in accordance with EN-LI-102 was a
performance deficiency. Specifically, Entergy did not adequately develop and
implement the Targeted Performance Improvement Plans, which were designated as
a CAPR of the root cause for the Nuclear Safety Culture Fundamental Problem. The
performance deficiency was more than minor because if left uncorrected, it could
lead to a more significant safety concern. Specifically, inadequate implementation of
the Targeted Performance Improvement Plans could result in recurrence of a culture
where leaders are not holding themselves and their subordinates accountable to high
standards of performance, resulting in continuing performance issues at the station.
The NRC team evaluated the finding using Exhibit 2, Mitigating Systems Screening
Questions, of IMC 0609, Appendix A, Significance Determination Process for
Findings At-Power, and determined this finding did not affect the design or
qualification of a mitigating structure, system, or component; represent a loss of
system and/or function; involve an actual loss of function of at least a single train or
two separate safety systems for greater than its technical specification-allowed
outage time; or represent an actual loss of function of one or more non-technical
specification trains of equipment designated as high safety-significant. Therefore,
the NRC team determined the finding was of very low safety significance (Green).
This finding had a cross-cutting aspect in the area of Human Resources, Change
Management, because leaders did not use a systematic process for evaluating and
implementing change so that nuclear safety remains the overriding priority. In this
case, PNPS leaders did not apply sufficient rigor in the development and
implementation of Targeted Performance Improvement Plans such that they would
be an adequate method to drive and sustain positive changes in the stations safety
culture [H.3].
Enforcement. Entergy failed to adequately develop and implement a CAPR of a root

cause related to a Category A CR, as required by Entergy procedure EN-LI-102,
Enclosure
162
Corrective Action Program. Specifically, Entergy did not adequately develop and
implement the Targeted Performance Improvement Plans, which were designated as
a CAPR for the root cause for the Nuclear Safety Culture Fundamental Problem.
The NRC team did not identify a violation of regulatory requirements associated with
this finding. The issue was entered into Entergys corrective action program as CR-
PNP-2017-00406. Because this finding does not involve a violation and is of very
low safety or security significance (Green), it is identified as a finding. (FIN
05000293/2016011-11, Failure to Adequately Develop and Implement Targeted
Performance Improvement Plans)
7.2 NRC Independent Safety Culture Assessment (IP 95003, Section 02.07)
The NRC team assessed PNPSs safety culture by conducting focus groups,
interviews, behavioral observations, and document reviews. The NRC team
conducted a total of 20 focus groups and 29 individual interviews which included
questions related to all 10 traits that comprise a safety culture. In all, the NRC team
interviewed 188 staff, supervisors, and managers, representing about 30 percent of
the workforce at PNPS. The NRC team also conducted behavioral observations to
gain insights on how work is being performed in the field. The information from the
focus groups, interviews, and behavioral observations was rolled-up into themes
which are discussed in this report.
In addition to the focus groups and interviews, the NRC team conducted document
reviews, which included CRs, root cause evaluations, the independent Third Party
Nuclear Safety Culture Assessments for both 2015 and 2016, and the recent PNPS
Baseline Survey Analysis Report completed in December 2016. The NRC team also
completed a comprehensive review of PNPSs Employee Concerns Program, as well
as the Executive Review Board process for screening disciplinary actions. Finally,
the NRC team evaluated the Nuclear Safety Culture Monitoring Panel and Safety
Culture Leadership Team meetings to verify whether they were effective methods for
understanding safety culture at PNPS.
In general, the NRC teams independent safety culture assessment confirmed the
results of PNPSs Third Party Nuclear Safety Culture Assessment, which noted
weaknesses in most areas. The general consensus among the focus group and
interview participants was that safety culture at PNPS was much improved. Most
participants perceived that there had been a marked change in leaderships focus on
safety over production over the past year or so. Participants noted that there was a
new emphasis on procedure use and adherence and procedure quality, as well as
improvements in conservative decision-making. Additionally, personnel felt that they
were able to trust management up through the Site Vice President.
Despite the improved safety culture, PNPS was still challenged with translating the
safety culture beliefs into repeatable, sustainable safety culture behaviors. The NRC
team determined that some station personnel, including operators, technicians,
supervisors, and management, were challenged to routinely exhibit site standards
and expectations when performing normal duties and responsibilities in areas such
Enclosure
163
as conservative decision-making, work practices, and procedure use and adherence.

The NRC team concluded that this may be due to a number of factors, including the
planned permanent shutdown of PNPS in 2019, and the lack of effective
benchmarking to understand what normal industry standards consist of relative to
issues in the organization, as well as the time it typically takes to change the safety
culture of an organization.
Station personnel did note some challenges during the focus groups and individual
interviews. Most personnel at all levels indicated that resource challenges continued
to impact their ability to accomplish work. Though most staff indicated that the
corrective action program had improved, some expressed concern that when
contractor support was no longer at the station, PNPS would revert to past
behaviors. Some staff also perceived that with regards to accountability, supervisors
and managers were not held to the same standard as non-supervisory employees.
Some personnel noted weaknesses in the work planning and scheduling processes,
especially related to emergent work.
Nearly all personnel interviewed and in focus groups stated that they felt free to raise
nuclear safety concerns through many avenues, including their supervisors, the
corrective action program, the Employee Concerns Program, and the NRC.
However, the NRC team noted that concerns related to one event could be
precursors to a potential chilled work environment in the radiation protection
department (Section 7.8). Additionally, the NRC team noted some general
frustration in the security department related to areas such as use of the corrective
action program, resources, respectful work environment, and consideration during
work planning. Despite these issues, the NRC team determined that the security
department would still raise nuclear safety concerns through the available avenues.
Finally, the NRC team noted some weaknesses in implementation of the Executive
Review Board, Employee Concerns Program, and the Nuclear Safety Culture
Monitoring Panel. Examples included an issue that was not evaluated by the
Executive Review Board even though it was required by Entergy procedure, issues
with Employee Concerns Program Coordinator qualifications, and rigor associated
with review of items at the Nuclear Safety Culture Monitoring Panel.
The NRC team assessed PNPSs behaviors and performance in each of the IMC
0310 safety culture traits. Traits, attributes, and examples are referenced within
NUREG 2165, Safety Culture Common Language. It is important to note that
results of the focus groups and interviews represented the perceptions of those
interviewed, unless otherwise noted.
.1 Assessment of the Leadership Safety Values and Actions Trait
The Leadership Safety Values and Actions trait states that leaders demonstrate a
commitment to safety in their decisions and behaviors. The associated attributes
include:
Resources (H.1): Leaders ensure that personnel, equipment, procedures,

and other resources are available and adequate to support nuclear safety.
Enclosure
164
Field Presence (H.2): Leaders are commonly seen in working areas of the
plant observing, coaching, and reinforcing standards and expectations.
Deviations from standards and expectations are corrected promptly.
Incentives, Sanctions and Rewards (X.1): Leaders ensure incentives,

sanctions, and rewards are aligned with nuclear safety policies and reinforce
behaviors and outcomes that reflect safety as the overriding priority.
Strategic Commitment to Safety (X.2): Leaders ensure plant priorities are

aligned to reflect nuclear safety as the overriding priority.
Change Management (H.3): Leaders use a systematic process for evaluating

and implementing change so that nuclear safety remains the overriding
priority.
Roles, Responsibilities, and Authorities (X.3): Leaders clearly define roles,

responsibilities, and authorities to ensure nuclear safety.
Leader Behaviors (X.5): Leaders exhibit behaviors that set the standard for
safety.
Most personnel interviewed and in focus groups indicated that there had been a
marked change in leaderships focus on safety over production over the past year or
so, in that manager communications and actions emphasized nuclear safety as
paramount. There had been more open dialogue on safety and better conversations
when individuals have questions on which work should be prioritized based on
nuclear safety. There was a new emphasis on procedure use and procedure quality
as well as stop when unsure. Conservative decision making was viewed as an
area which had improved. Most personnel had positive input concerning PNPSs
Site Vice President as well as Entergys Chief Nuclear Officer with respect to their
emphasis on safety and safety culture and doing the right thing even if it means
stopping or shutting down the plant. Most personnel interviewed indicated that
management was more visible in the field, but still seemed to spend the majority of
their time in meetings.
Most personnel at all levels indicated that resource challenges continued to impact
their ability to accomplish work. Most focus groups described examples of
insufficient numbers of qualified personnel to perform specialized tasks; training
being rescheduled due to workload or conflicts with availability of support
organizations such as security; excessive overtime; and reliance on contractor
support rather than hiring the staff needed. (For additional discussion on staffing
adequacy, refer to Section 7.1.3 of this report).
All personnel agreed that leadership emphasized safety as the top priority. Everyone
interviewed said that they would use the corrective action program and felt
comfortable with leaderships expectation to stop work when unsure or when
questions exist. The general consensus from the interviews was that safety culture
at PNPS was much improved. However, as discussed throughout this report, the
NRC team noted examples of actual behaviors that were contrary to the results of
Enclosure
165
the focus groups and interviews (see Sections 6.1.3 and 6.2.3 of this report for
examples).
The NRC teams independent safety culture assessment confirmed the results of
PNPSs nuclear safety culture assessments and cause evaluations within the
Leadership Safety Values and Actions trait which indicated that the senior leadership
team had not been consistently engaged in demonstrating and demanding higher
levels and standards of performance from the site. Although interviews and focus
groups indicated that leadership team behaviors have changed in a positive
direction, actual behaviors observed by the NRC team provide conflicting
information. The NRC team concluded that actions being taken by leadership, such
as continued emphasis on safety and conservative decision making mentioned
above, if continued, should have a positive effect on PNPSs safety culture.
.2 Assessment of the Problem Identification and Resolution Trait
The Problem Identification and Resolution trait states that issues potentially
impacting safety are promptly identified, fully evaluated, and promptly addressed and
corrected commensurate with their significance. The associated attributes include:
Identification (P.1): The organization implements a corrective action program

with a low threshold for identifying issues. Individuals identify issues
completely, accurately, and in a timely manner in accordance with the
program.
Evaluation (P.2): The organization thoroughly evaluates problems to ensure

that resolutions address causes and extent of conditions, commensurate with
their safety significance.
Resolution (P.3): The organization takes effective corrective actions to

address issues in a timely manner, commensurate with their safety
significance.
Trending (P.4): The organization periodically analyzes information from the
corrective action program and other assessments in the aggregate to identify
programmatic and common cause issues.
All individuals interviewed or in focus groups indicated that more focus had been
placed on how to identify issues and enter them into the corrective action program.
Most staff felt that improvements via training and leadership have led to an improved
corrective action program. There was widespread familiarity with how to initiate a
CR, and personnel indicated that their supervisors desired for them to get the CR
into the right hands so that identified conditions could be corrected. There was also
general consensus that CR thresholds are now very low, which resulted in more CRs
being written. However, some personnel expressed that the corrective action
program became saturated with insignificant or repeat CRs in order to manage the
ratio of an internally to externally identified CR metric. This resulted in additional
stress on personnel to deal with extraneous CRs. Some staff expressed that many
of the identified issues need multiple CRs in order for the condition to be resolved.
Staff recognized the positive impact provided by the contractors who were hired to
focus on apparent and root cause evaluations. However, some personnel did
Enclosure
166
express concern that when the contractor support was no longer at PNPS, old ways
of doing business would begin again. While most personnel believed that issues are
addressed in a timely manner, the site still needed improvement with disposition of
issues as non-adverse or adverse. Staff felt that improvements to the Corrective
Action Review Board process have led to CRs being conservatively categorized as
adverse.
Across the corrective action program organization, a focused effort was implemented
to define roles, responsibilities, and training for multiple positions. In addition,
Entergy hired subject matter experts and contractors to ensure qualified staff was
available and manpower matched workload for the corrective action program. The
NRC team noted that Entergy had streamlined the job-specific responsibilities for the
department performance improvement coordinators. PNPS personnel felt that these
corrective actions have led to an overall reduction in the backlog of open CRs.
Station-wide training focused on how to use the stations software to initiate a CR
and the life cycle of a CR. Although all personnel reported receiving feedback when
a CR they wrote was closed, the feedback was typically an automated email
indicating the CR had been closed without providing details regarding what was done
in response to the problem. Personnel were encouraged to write follow-up CRs if
they disagreed with how the CR was closed.
During focus groups and interviews, some security personnel expressed frustration
over the use of corrective action program. They did not feel encouraged to write
CRs, however, they did not express any hesitancy to use the corrective action
program. They also expressed frustration with status and resolution of CRs that
were placed in the corrective action program. Examples were discussed that pointed
to inconsistency in training and use of the corrective action program at the site.
PNPSs nuclear safety culture assessments and cause evaluations within the
Problem Identification and Resolution trait. PNPS identified the corrective action
program as a fundamental problem during their recovery evaluations. The NRC
teams assessment of this area is discussed in more detail in Section 5.1 of this
report.
.3 Assessment of the Personal Accountability Trait
The Personal Accountability trait states that all individuals take personal
responsibility for safety. The associated attributes include:
Standards (X.6): Individuals understand the importance of adherence to

nuclear standards. All levels of the organization exercise accountability for
shortfalls in meeting standards.
Job Ownership (X.7): Individuals understand and demonstrate personal

responsibility for the behaviors and work practices that support nuclear
safety.
Enclosure
167
Teamwork (H.4): Individuals and workgroups communicate and coordinate

their activities within and across organizational boundaries to ensure nuclear
safety is maintained.
All personnel interviewed and in focus groups communicated that they have a high
commitment to nuclear safety and accountability. Most personnel expressed a
desire to return PNPS to a high-performing site and sustain the performance until
decommissioning. All expressed the need for individuals to be held accountable for
their personal performance, and that they believe this has improved over the past
few years. While most non-supervisory personnel believed that site leadership was
now placing appropriate emphasis on personal accountability, some expressed
uneasiness regarding whether all employees are held to the same standards.
One area where some non-supervisory personnel expressed concern was the
perception that supervisors and managers were not held accountable to the same
standards as non-supervisory employees. Some non-supervisory personnel
expressed that at the worker level, a mistake would be punished, while a manager
who makes a mistake is simply transferred to another department, or to another
Entergy plant, with no perceived consequences. They also expressed frustration
that senior leadership did not seem to be held accountable for making non-
conservative decisions, such as the decision to continue operating the plant despite
an impending winter storm (January 2015), resulting in high consequences for the
site.
PNPSs nuclear safety culture assessments which identified personal accountability
as an area of concern. The NRC team noted that two of the three personal
accountability attributes (i.e., standards and ownership) are not used for
determination of cross-cutting aspects during baseline NRC inspections, so there
was limited data from NRC inspections. Focus group discussions, individual
interviews, and field observations support the conclusion that personal accountability
had been a nuclear safety culture problem at PNPS, although there had been
notable improvement recently.
.4 Assessment of the Work Processes Trait
The Work Process trait states that the process of planning and controlling work
activities is implemented so that safety is maintained. The associated attributes
include:
Work Management (H.5): The organization implements a process of

planning, controlling, and executing work activities such that nuclear safety is
the overriding priority. The work process includes the identification and
management of risk commensurate to the work.
Design Margins (H.6): The organization operates and maintains equipment

within design margins. Margins are carefully guarded and changed only
through a systematic and rigorous process. Special attention is placed on
maintaining fission product barriers, defense-in-depth, and safety-related
equipment.
Enclosure
168
Documentation (H.7): The organization creates and maintains complete,

accurate, and up-to-date documentation.
Procedure Adherence (H.8): Individuals follow processes, procedures, and

work instructions.
Most individuals interviewed or in focus groups indicated that resource issues

negatively impacted the work management process. Individuals stated that as
people left they were not replaced. Some stated that the Fix-it-Now team was
understaffed and used for the wrong purposes such as installing modifications.
Some stated maintenance resources were diverted from scheduled items to perform
unscheduled corrective maintenance. Security officers stated that lack of resources
had occasionally challenged time critical tasks.
Some personnel stated that they felt there were weaknesses in the planning and
scheduling processes and that work was sometimes emergent and unscheduled.
Some personnel indicated the T-week planning process needed the most
improvement, and that the scheduling margin was such that emergent issues forced
resources away from planned work. Most radiation protection technicians and
security officers felt that no work planning or scheduling consideration was given to
either of their groups. Security officers stated that delivery vehicles were often
forced to wait hours for processing and at times turned away due to unavailability of
security resources. Several stated that hiring contract planners had improved the
work management process. Some noted that unplanned work was not hitting them
out of the blue as it had in the past.
In addition, most personnel said that procedures were of high quality and easy to
correct. Others stated that the fleet procedure program made it hard to reconcile
local procedure issues, at times requiring weeks or months to implement a change.
Maintenance personnel stated that Fix-it-Now team work packages were of high
quality due to the skill of the Fix-it-Now team planners, whereas shop maintenance
packages had many errors due to cut and paste of information between
documents.
Individuals described coordination between groups as a struggle, but improving, and
indicated that coordination became challenging when there was unscheduled work.
Some workers stated that supervisors routinely put them under time pressure.
Some engineers stated that they had to champion planning, scheduling, field work,
and testing in order to complete critical work and preventive maintenance. Some
individuals described long delays in fixing equipment and rework after repairs.
Others described a loss of the big picture in that small things got fixed to the
detriment of fixing major items. Operation supervisors, however, stated that they had
station management support for priority issues and received support as needed from
other departments.
The NRC team observed emergent corrective maintenance and calibration of an

average power range monitor flow converter in the main control room. During the
evolution, the NRC team observed technicians and operators appropriately use
standard human performance tools, coordinate on expected alarms and indications,
and practice formal three-way communication. Although maintenance continued
during operations shift turnover, there was no loss of maintenance focus on the task
and no degradation of operator awareness. This emergent maintenance was
Enclosure
169
successfully performed over multiple shifts during a half scram condition to meet
technical specification limiting condition for operation requirements.
PNPSs nuclear safety culture assessments with respect to the work processes trait,
which determined that the work planning and scheduling process was implemented
poorly and was not adequately supporting the ability to accomplish work. Most focus
groups indicated that availability of resources impacted the implementation of
PNPSs work management process, and at times, the station responded to emergent
safety and production issues at the expense of scheduled corrective and preventive
maintenance. The NRC team did not identify any evidence or reason to believe that
Entergy management would aggressively address self- and independently-identified
work management process issues as long as minimum regulatory requirements to
allow continued operation were satisfied. Entergy identified work management as a
problem area during their recovery evaluations. The NRC teams assessment of this
area can be found in Section 6.13 of this inspection report.
.5 Assessment of the Continuous Learning Trait
The Continuous Learning trait states that opportunities to learn about ways to ensure
safety are sought out and implemented. The associated attributes include:
Operating Experience (P.5): The organization systematically and effectively

collects, evaluates, and implements relevant internal and external operating
experience in a timely manner.
Self-Assessment (P.6): The organization routinely conducts self-critical and

objective assessments of its programs and practices.
Benchmarking (X.8): The organization learns from other organizations to

continuously improve knowledge, skills, and safety performance.
Training (H.9): The organization provides training and ensures knowledge

transfer to maintain a knowledgeable, technically competent workforce and
instill nuclear safety values.
Many personnel interviewed and in focus groups indicated that they had concerns
about the continuous learning environment at PNPS. Some personnel were
concerned about a perceived lack of quality training, training that was computer-
based, and training that focused on memorization rather than how to perform a task.
Most personnel stated that there was little training available above the minimum
requirements, which was a noticeable decrease in how training was implemented in
the past.
When questioned about the recent safety culture assessments conducted at PNPS,
most personnel indicated awareness of the outcomes, as well as the specific actions
being taken by PNPS in response to the assessments.
Many management and non-supervisory personnel stated that benchmarking was

not performed as frequently in recent times as it has been in the past. The NRC
Enclosure
170
team noted that only eleven formal benchmarking activities have occurred from 2013
to present. During interviews, a few people also described occurrences of what they
considered to be benchmarking activities, however the NRC team noted these
activities did not appear to be documented using benchmark report guidance from
EN-LI-104 Self-Assessment and Benchmark Process.
Many individuals, excluding operators, indicated that training was a low priority at
PNPS, training quality had declined, training did not effectively support the work
process, and training attendance conflicted with work. One focus group indicated
training had been cut back to the bare minimum, from four times a year for four days
to once a year for three days. Others stated that training was needed for job
fundamentals such ability to read prints/drawings. Others stated that there was a
lack of qualified instructors.
PNPSs nuclear safety culture assessments, which noted that the organization is not
placing sufficient emphasis on key elements of continuous improvement, such as
self-assessment, industry benchmarking, operating experience, and self-criticalness.
.6 Assessment of the Environment for Raising Concerns Trait
The Environment for Raising Concerns trait states that a safety conscious work
environment is maintained where personnel feel free to raise safety concerns without
fear of retaliation, intimidation, harassment, or discrimination. The associated
attributes include:
Safety Conscious Work Environment Policy (S.1): The organization

effectively implements a policy that supports individuals rights and
responsibilities to raise safety concerns, and does not tolerate harassment,
intimidation, retaliation, or discrimination for doing so.
Alternate Process for Raising Concerns (S.2): The organization effectively

implements a process for raising and resolving concerns that is independent
of line-management influence. Safety issues may be raised in confidence
and are resolved in a timely and effective manner.
Nearly all personnel interviewed and in focus groups stated they felt free to raise
nuclear safety concerns through many avenues including: their supervisors, the
Corrective Action Program, the Employee Concerns Program, and the NRC.
However, the NRC team noted that the radiation protection workgroup expressed
concerns related to one event that could be precursors to a potential chilled
environment (see Section 7.8 of this report for more detail). Additionally, the security
workgroup expressed some concerns with the use of the Employee Concerns
Program. The PNPS Employee Concerns Program Coordinator was taking steps to
address workgroups at the site that had lower scores in some questions in the 2016
Third Party Nuclear Safety Culture Assessment survey related to the use of the
PNPS Employee Concerns Program. As of April 20, 2017, PNPS stated that the
next Nuclear Safety Culture Assessment results are planned to be compared to the
prior assessment to evaluate the effectiveness of the actions taken. The NRC team
noted that an EFR of these actions should confirm whether these actions have been
Enclosure
171
successful in increasing confidence in the Employee Concerns Program, especially

in the security workgroup.
The NRC team noted that there were no NRC inspection findings that were assigned
cross-cutting aspects within the environment for raising concerns safety culture trait.
PNPSs safety culture evaluations identified the safety conscious work environment
as a potential problem area. The station completed an apparent cause evaluation
and did not substantiate any issues with the environment for raising concerns.
PNPSs nuclear safety culture assessments related to the environment for raising
concerns trait. The NRC team noted that with the exception of the precursors in the
radiation protection workgroup, as discussed in Section 7.8, there are no ongoing
indications of potential issues with the environment for raising concerns.
.7 Assessment of the Effective Safety Communication Trait
The Effective Safety Communication trait states that communications maintain a

focus on safety. The associated attributes include:
Work Process Communications (X.9): Individuals incorporate safety

communications in work activities.
Bases for Decisions (H.10): Leaders ensure that the basis for operational
and organizational decisions is communicated in a timely manner.
Free Flow of Information (S.3): Individuals communicate openly and

candidly, both up, down, and across the organization, and with oversight,
audit, and regulatory organizations.
Expectations (X.10): Leaders frequently communicate and reinforce the

expectation that nuclear safety is the organizations overriding priority.
Most personnel interviewed and in focus groups felt that site management had
improved in communicating their focus on improving safety, and identified the use of
additional communication tools such as site daily newsletters, a SharePoint site
(AirsWeb), videos, emails, signage, recordings, and quarterly all-hands meetings.
Management has placed additional emphasis on procedural adherence. Senior
Management has consistently communicated via a weekly safety message to follow
the process and complete the task without regard to production. Most personnel
interviewed stated that senior management is improving at informing plant personnel
of safety-significant or risk-significant issues via plan-of-the-day communications.
Managers are also more engaged in meeting with key personnel on a more frequent
basis to understand issues and address questions. Station personnel also conveyed
that management changed a practice from closed top-level meetings to conducting
informed follow-up debriefs with employees to ensure more transparency and
openness.
Enclosure
172
Employees felt empowered to stop work and actively participate in stand-down

meetings. Individuals indicated that there had been more open dialogue on safety
and better conversations when individuals had questions on which work should be
prioritized based on nuclear safety. While communication methods and frequency
had improved for most, security personnel did not feel as informed, felt that
information was inconsistently shared from the top down, and felt communications
were not pertinent to them. Security staff indicated that they did not have
opportunities to interact with site senior leadership due to the inability to attend the
all-hands meetings while standing watch.
PNPSs nuclear safety culture assessments and cause evaluations within the nuclear
safety culture trait of effective safety communication. The NRC team concluded that
PNPS developed appropriate corrective actions to improve performance in the
effective safety communication trait.
.8 Assessment of the Respectful Work Environment Trait
The Respectful Work Environment trait states that trust and respect permeate the
organization. The associated attributes include:
Respect is Evident (no IMC 0310 code): Everyone is treated with dignity and
respect.
Opinions are Valued (no IMC 0310 code): Individuals are encouraged to
voice concerns, provide suggestions, and raise questions. Differing opinions
are respected.
High Level of Trust (no IMC 0310 code): Trust is fostered among individuals
and work groups throughout the organization.
Conflict Resolution (no IMC 0310 code): Fair and objective methods are
used to resolve conflicts.
Personnel felt that they were able to trust management up through the Site Vice
President. They trusted that the new senior management team was moving the
station in the right direction. The majority of personnel interviewed and in focus
groups felt that they were respected for the work that they contributed to the station
and that they worked in a respectful work environment. However, focus groups and
interview participants stated that although site security has not been compromised,
most members of the security organization felt disrespected by plant management
due to a lack of a retention bonus contract before the impending plant closure.
Security officers stated that changes in policy, procedures, and work hours occur
randomly and without input from the security officers. Security officer dissatisfaction
was documented in numerous anonymous CRs. The NRC team confirmed that in
spite of the sometimes tense relationship between management and security
officers, changes to security policy and procedures were accomplished in
accordance with the corrective action program and communicated to security officers
via daily roll call packets.
Enclosure
173
The focus groups also indicated that radiation protection personnel did not feel like
they were respected. Some examples provided include plant personnel interrupting
their work; plant personnel not understanding the scope and time associated with
radiation protection work; and not accounting for radiation protection support during
work planning, which results in resource strains to the department to provide
unscheduled coverage.
Overall, the NRC team concluded that, with some exceptions as noted, there is a
respectful work environment at the station.
.9 Assessment of the Questioning Attitude Trait
The Questioning Attitude trait states that individuals avoid complacency and
continuously challenge existing conditions and activities in order to identify
discrepancies that might result in error or inappropriate action. The associated
attributes include:
Nuclear is recognized as Special and Unique (no IMC 0310 code):

Individuals understand that complex technologies can fail in unpredictable
ways.
Challenge the Unknown (H.11): Individuals stop when faced with uncertain
conditions. Risks are evaluated and managed before proceeding.
Challenge Assumptions (X.11): Individuals Challenge Assumptions and offer

opposing views when they think something is not correct.
Avoid Complacency (H.12): Individuals recognize and plan for the possibility
of mistakes, latent problems and inherent risk, even while expecting
successful outcomes.
Most individuals interviewed and in focus groups stated that they would feel
comfortable challenging their immediate supervisor or manager if they felt they were
not able to get an issue resolved. Individuals stated that they felt they had stop-work
authority, would not hesitate to stop work or stop when unsure, and there would be
no retaliatory action for doing so. Participants in the focus groups and interviews
also stated that in many cases, people were acknowledged and sometimes rewarded
for stopping work when conditions were challenging.
However, during field observations and document reviews, the NRC team identified
several examples that demonstrated an inadequate questioning attitude by the
station:
PNPS did not adequately question or evaluate the adverse effects of running
the A emergency diesel generator cooling fan right-angle gear drive without
pressurized lubrication (refer to Section 6.7.4 of this report for a detailed
discussion of this issue).
The NRC team observed PNPSs preparations for a core spray system logic
surveillance test, including multiple pre-job briefings and a control room brief.
Enclosure
174
The control room authorized and then subsequently decided to stop the test
when the NRC team questioned the evaluation of risk for the evolution due to
conflicting information that was presented regarding risk. The same
information was available to multiple PNPS staff who participated in the
briefings, yet none of them questioned the conflicting information.
The NRC team concluded that the general willingness of station personnel to stop
work and raise concerns when they are in doubt is a positive cultural attribute.
Additionally, in focus group interviews, most PNPS personnel stated that site
performance has improved dramatically, especially over the past few years.
However, the NRC team also noted that in order for an individual to raise a concern
or challenge an assumption, they must first recognize that there is, or might be, an
issue (i.e., frame of reference with current standards). PNPSs challenges with
frame of reference may be partially due to placing insufficient priority on
benchmarking of industry peers as previously noted, the station has only
completed 11 formal benchmarking activities since 2013, while other planned
benchmarking activities had been cancelled. The NRC team concluded that on an
individual and collective level, the station is not sufficiently self-critical, making
comparisons only with their own past performance rather than that of their industry
peers. This is in line with the 2016 Third Party Nuclear Safety Culture Assessment
results, which noted that the PNPS organization (and the Entergy fleet) has become
overly insular and disconnected from an accurate understanding of current industry
best practices, which contributed to an organizational frame of reference deficiency.
.10 Assessment of the Decision-Making Trait
The Decision-Making trait states that healthy decision-making for activities that
support or affect nuclear safety is systematic, rigorous, and thorough. Attributes
associated with healthy decision making include:
Consistent Process (H.13): Individuals use a consistent, systematic

approach to make decisions. Risk insights are incorporated as appropriate.
Conservative Bias (H.14): Individuals use decision-making practices that

emphasize prudent choices over those that are simply allowable. A proposed
action is determined to be safe to proceed, rather than unsafe in order to
stop.
Avoid Complacency (H.12): Individuals recognize and plan for the possibility
of mistakes, latent issues, and inherent risk, even while expecting successful
outcomes. Individuals implement appropriate error reduction tools.
Accountability for Decisions (X.12): Single-point accountability is maintained

for nuclear safety decisions.
Most individuals interviewed and in focus groups stated, with few exceptions, that
PNPS management made conservative decisions. Examples discussed included:
Many participants cited the plant shutdown during a recent winter storm.
Enclosure
175
Some described the decision to delay unit startup to perform switchyard

maintenance after an individual raised a safety concern over a breaker
disconnect hotspot.
Some referred to the plant shutdown in 2016 to repair an excessive feed

water regulation valve packing leak.
However, focus group and interview participants did note some examples of non-
conservative decision-making at the station, including:
Some noted the decision to start up the plant in 2015 with a packing leak
from a feedwater regulating valve.
One individual described a 2016 decision related to a defective salt service

water strainer pressure indicator as an example and stated, If the work-
around for broken equipment met minimum NRC safety requirements, the
equipment was not repaired.
Some individuals provided examples of degraded security-related equipment

that went unfixed with compensatory work arounds in place.
Some individuals described an informal, non-conservative backshift

decision-making philosophy that is perceived to prioritize production.
Workers stated that work is delayed on dayshift because issues go through
committees, groups, and meetings, but on backshift, you do what you have
to do to get the job done; you do the job now and do the paperwork later;
results over process; some higher risk jobs are only done on backshift. An
individual cited an example of completing work in a high radiation area that
would have never happened on dayshift.
The NRC team also reviewed the decision-making aspects related to an entry into an
unplanned technical specification limiting condition for operation for inoperable main
steam isolation valves. The technical specification requires that if a main steam
isolation valve is inoperable, the steam line must be isolated or the plant shut down
within specified time limits. When the station confirmed that two main steam
isolation valves were inoperable, the shift manager immediately ordered the isolation
of one of the main steam lines. The second steam line, however, could not be
immediately isolated because there were no procedures for two steam line operation
at the existing power level. The shift manager conservatively ordered operators to
lower reactor power and reactor pressure to a level at which the plant was analyzed
for two steam line operation. The shift manager then ordered the second main
steam line isolated. The operators then completed the reactor shutdown to repair
the main steam isolation valves.
Originally, the shift manager determined that when operators started to lower reactor
power, a report to the NRC was required within four hours per 10 CFR 50.72(b)(2)(i),
and the NRC Senior Resident Inspector was notified as such. After consultation with
operations management, the shift manager determined that a four-hour report was
not required and the report was not made. Though the station took appropriate
actions with regards to operation of the plant, the NRC team questioned the
Enclosure
176
reasoning behind the reportability decision. This issue will be dispositioned in the
first quarter 2017 integrated inspection report.
With the exception of site security officers, during formal interviews and focus
groups, most stated that management involved the entire team in the decision-
making process and adequately communicated decisions that affect nuclear safety
and site security. Operators stated there was an open line of communication up and
down the chain of command and that decisions and the bases behind decisions were
communicated during pre-job briefs, turnovers, and equipment out-of-service briefs.
Others stated that people were able to challenge managerial and supervisory
decisions and empowered with the authority to stop work.
The NRC team confirmed the results of PNPSs safety culture assessments within
the decision-making trait, which determined that there continues to be inconsistent
performance in this area. Based on the examples provided above, the NRC team
concluded that PNPS did not consistently exhibit alignment with nuclear safety
culture attributes for conservative decision-making. When challenged by events or
circumstances, PNPS operators prudently made decisions to place the plant in a
safe condition. However, it appears, at times, that the station passively accepted
and encouraged decision-making biased towards that which is expedient and
allowable over that which is prudent. PNPS identified decision-making/risk-mitigation
as a fundamental problem during their recovery evaluations. The NRC teams
evaluation of this area is discussed in more detail in Section 6.1 of this inspection
report.
7.3 Safety Culture and Safety Conscious Work Environment Policies
The NRC team reviewed the procedures and training governing safety culture and
safety conscious work environment to determine whether they are adequate to
support a robust nuclear safety culture and encourage personnel to report safety
concerns without fear of retaliation. The NRC team reviewed Entergy procedures
EN-PL-190, Maintaining a Strong Safety Culture, and EN-PL-187, Safety
Conscious Work Environment. In addition, the NRC team reviewed training
modules on safety culture and safety conscious work environment to support training
for PNPS staff, as well as supervisors and above.
The PNPS 2016 Third Party Nuclear Safety Culture Assessment identified a nominal
decline in nuclear safety culture and a nominal decline in safety conscious work
environment since the 2015 assessment.
The NRC team concluded that the procedures for safety culture and safety
conscious work environment were appropriate and were updated to include all safety
culture traits from NUREG-2165, Safety Culture Common Language. The NRC
Enclosure
177
team noted that EN-PL-187, Safety Conscious Work Environment, applies to all
employees and contractors while EN-PL-190, Maintaining a Strong Safety Culture
does not mention contractors.
The NRC team concluded that most PNPS personnel understood that safety culture
is the core values and behaviors resulting from a collective commitment by leaders
and individuals to emphasize safety over competing goals to ensure protection of
people and the environment, and that safety conscious work environment is an
atmosphere for raising concerns without fear of harassment, intimidation, retaliation,
or discrimination. PNPS management provided all employees with the Building Our
Legacy of Excellence booklet. This booklet referred to the traits of a healthy nuclear
safety culture as well as expectations for behaviors to obtain excellence.
In addition, all PNPS employees received training related to safety culture in 2016.
Entergy developed training module PGAT-ADM-NSCCAP, Improving our Nuclear
Safety Culture, under CR-PNP-2016-02052, CA-60, to ensure a common
understanding of the nuclear safety culture traits and how nuclear safety culture
influences nuclear safety performance. In addition, PGAT-ADM-NSCCAP supported
a secondary objective to provide safety conscious work environment training, to
ensure that employees understood that they could raise safety concerns without fear
of retaliation, under CR-PNP-2016-06113, CA-05. The majority of this classroom
training was completed by November 22, 2016. The NRC team noted that new hires
will not be included in this one-time training initiative. The NRC team observed this
training on December 7, 2016, and noted that case studies from the NRC Safety
Culture Policy Statement, as well as lessons learned from the nuclear safety culture
root cause evaluation (CR-PNP-2016-02052), were utilized for small group
discussions in this training session.
In addition to the above, the NRC team noted that other classroom and computer-
based training was also conducted related to safety culture:
FCBT-GET-PATSS, Entergy Fleet Plant Access, which all employees received,

discusses both the Employee Concerns Program and safety culture.
Entergy manual, EN-TQ-127, Supervisor Training Program, included reference

to FFAM-SUPV-00001, Supervisor Training Program Familiarization Guide.
This familiarization guide included a meeting with the Site Employee Concerns
Program Coordinator and a review of procedures EN-PL-187, Safety Conscious
Work Environment, EN-PL-190, Maintaining a Strong Safety Culture, and EN-
QV-136, Nuclear Safety Culture Monitoring.
Initial training for first line supervisors includes classroom training module FSEM-
SUPV-NSC, Nuclear Safety Culture, within one year from date of promotion or
hire into a supervisory role. All supervisors will now receive computer-based
training module FCBT-SUPV-NSC, Nuclear Safety Culture, Revision 0, as a
prerequisite for FSEM-SUPV-NSC.
The NRC team concluded that training for supervisors and above in the area of
safety culture and safety conscious work environment is adequate.
Enclosure
178
7.4 Executive Review Board
The NRC team evaluated Entergys Executive Review Board process to determine
whether PNPS employees were encouraged to report safety-related concerns
without fear of retaliation, and that control measures or policies were being
implemented. The NRC team reviewed procedure EN HR-138, Executive Review
Board Process for Employees, reviewed seven selected Executive Review Board
files from the last year, interviewed the human resources representative from PNPS,
and reviewed procedure EN-HR-138-1, Executive Review Board Process for
Supplemental Personnel. The purpose of the Executive Review Board process is to
review certain personnel actions to ensure that the actions do not create a chilling
effect in the affected work group and/or other workgroups on site.
The NRC team noted that the Executive Review Board documented actions in
accordance with the process, including identifying if an individual had participated in
a protected activity. In addition, the NRC team verified that in general, the Executive
Review Board identified the potential for creating chilling effects when used
appropriately.
The NRC team concluded that the process and procedures used to guide the
Executive Review Board were appropriate. However, the NRC team identified one
instance where PNPS did not ensure that all actions that warrant review by the
Executive Review Board were identified. During focus groups, the NRC team
learned of an Ethics Hotline incident perceived by workers as punitive. An individual
had been removed from duty while Entergy investigated the hotline allegation.
Although the hotline allegation was not substantiated and the individual returned to
work without loss of pay or punishment, the removal of the individual was not
evaluated by the Executive Review Board for a potential chilling effect on other
employees. This is contrary to EN-HR-138, Section 5.4[1], which states, in part, that
the Executive Review Board shall review the following proposed actions: disciplinary
action resulting in a suspension or termination; involuntary removal from duties;
denial or removal of unescorted access; and any actions or issues that the Executive
Review Board, in its discretion, believes may have the potential to create a chilling
effect. The NRC team determined this procedure non-compliance was minor in
accordance with IMC 0612, Appendix B, because it was not a precursor to a
significant event, would not lead to a more significant safety concern, did not cause a
performance indicator to exceed a threshold, and did not affect one of the
cornerstone objectives. This issue did not result in a chilled work environment in the
affected department. Entergy documented this issue in the corrective action
program under CR-PNP-2017-02684.
Enclosure
179
7.5 Employee Concerns Program
The NRC team completed a review of the PNPS Employee Concerns Program,
including a review of governing procedures, documentation of concerns,
documentation of corrective actions, feedback to employees, evaluation of concerns,
and any hesitancy to raise safety concerns. In addition, the NRC team evaluated the
self-assessment process and the expertise to determine whether weaknesses in the
Employee Concerns Program existed that could adversely impact PNPSs ability to
maintain a safety conscious work environment. The inspectors also reviewed
training related to the Employee Concerns Program, and conducted interviews with
the PNPS Employee Concerns Program Coordinator and the Entergy Corporate
Employee Concerns Program Manager.
Based on a review of files from 2015 and 2016, the NRC team determined that
documentation in the files was sufficiently detailed to demonstrate appropriate
processing of the concern, including resolution and feedback to the employee. The
NRC team also determined that PNPS appropriately maintained Employee Concerns
Program records in a secure location accessible only to the Employee Concerns
Program staff. The NRC team concluded that processes and procedures used to
implement the Employee Concerns Program at PNPS were appropriate. However,
the NRC team did note some weaknesses in implementation of the program and
instances where PNPS did not meet the requirements outlined in the Employee
Concerns Program process procedures, as described below.
Upon review of the qualification requirements for the station Employee Concerns
Program Coordinator, the NRC team determined that at the time of this inspection,
the PNPS Employee Concerns Program Coordinator was not fully qualified and
could not complete an investigation independently. The NRC team identified that
Entergy procedure EN-EC-100-01, Employee Concern Coordinator Training
Program, Revision 1, Attachment 9.1, and FFAM-ECPI-INIT, Employee Concerns
Coordinator Familiarization Guide, contain required training courses that were not
available. Based on the NRC teams questions, Entergy documented this issue in
CR-PNP-2016-09705 and CR-HQN-2016-01611. Planned corrective actions include
revising the applicable procedures to document the replacement training courses,
and scheduling the appropriate training for the PNPS Employee Concerns Program
Coordinator. The NRC team also noted that the Entergy Corporate Employee
Concerns Program Manager, as well as the Employee Concerns Program
Coordinators from other Entergy sites are available, as needed, until the PNPS
coordinator completes the required qualifications.
During review of Employee Concerns Program files, the NRC team identified that in
at least one instance, an issue was classified as a Rapid Response case although
the issue clearly involved safety conscious work environment. In accordance with
Enclosure
180
Entergy procedure EN-EC-100, Guidelines for Implementation of the Employee

Concerns Program, this type of case should have warranted a full Employee
Concerns Program case file. The NRC team also noted that the current Employee
Concerns Program Coordinator completed this investigation after having only been in
the position for two weeks. Although the existing practice allowed for an unqualified
Employee Concerns Program Coordinator to complete a Rapid Response case with
mentoring, a full Employee Concerns Program case file would have required a fully
qualified coordinator to complete. The NRC team reviewed this case file and
determined that despite this issue, this case appeared to be resolved appropriately.
PNPS entered this issue into their corrective action program as CR-PNP-2017-
02685.
The NRC team noted that the Employee Concerns Program files for substantiated
cases included documentation of recommended actions from the Employee
Concerns Program coordinator to the Site Vice President. However, information
regarding the disposition of those corrective actions was not included in the
corrective action program or the normal tracking system, TrakWeb, as required by
Entergy procedure EN-EC-100, Guidelines for Implementation of the Employee
Concerns Program. Per EN-EC-100, Section 5.17, Open Corrective Action
Tracking, the Employee Concerns Program coordinator is responsible for ensuring
that corrective actions are completed. Of the five files reviewed by the NRC team, all
that included recommended or required corrective actions did not have the corrective
actions entered into the corrective action program or tracked in TrakWeb. Based on
interviews with Employee Concerns Program personnel, the NRC team determined
that the station was using informal methods to track completion of these actions,
instead of TrakWeb, and ANO was the only Entergy site consistently using this
program. Notwithstanding the above, the NRC team did not find evidence of any
actions that should have been completed but were not. The Entergy fleet Employee
Concerns Program Manager has since reinforced the expectation that TrakWeb be
used to track related corrective actions and follow-up activities, as required by
procedure. Entergy entered this issue into their corrective action program as CR-
PNP-2017-02686.
The NRC team evaluated each of these performance deficiencies in accordance with
IMC 0612, Appendix B, and determined that each of these issues were minor.
Specifically, none of the issues represented a precursor to a significant event, would
have the potential to lead to a more significant safety concern, caused a
performance indicator to exceed a threshold, or adversely affected a cornerstone
objective.
Though not required by Entergy process, the NRC team did note the following:
When requested, the Employee Concerns Program Coordinator had difficulty

retrieving files. Related concerns were filed together, in some cases, which
can make retrieval especially difficult as well.
The NRC team noted that in some cases, Employee Concerns Program files
did not have any information on monitoring the status of corrective actions or
any EFRs of corrective actions. Though EFRs are not required by Entergy
procedure EN-EC-100, conduct of EFRs is an industry best practice.
Enclosure
181
The NRC team noted that the Employee Concerns Program procedures and
guidelines did not address metrics; however, timeliness data, etc., was
provided to Entergy Corporate for reporting purposes. No goals for
timeliness were in place for PNPS or other Entergy sites other than ANO.
Consequently, there were no standards in place to measure timeliness of
completing reviews.
The NRC team noted that in accordance with EN-EC-100, Section 5.15,
Reporting Investigation Results, the Program User Feedback Form is
provided to a concerned individual at the time the investigation results are
communicated. The PNPS Employee Concerns Program Coordinator was
not reviewing or trending the results of these feedback forms in order to
determine whether improvements to the program were needed; the forms
were kept in the individual case files and only those with immediate actions
were forwarded to the Corporate Employee Concerns Program Manager for
action. Although there is no procedural requirement to trend these results for
potential improvements, this is an industry practice.
Overall, the NRC team concluded that the process and procedures used to
implement the Employee Concerns Program function were appropriate; however, not
all procedure requirements were met, as described above. The results from focus
group discussions conducted by the NRC team indicated that station personnel were
willing to raise concerns using the Employee Concerns Program. A review of NRC
allegation activity at PNPS did not result in any information that suggested a safety
conscious work environment issue or any issues with the Employee Concerns
Program at the station.
7.6 Nuclear Safety Culture Monitoring Panel
The NRC team assessed the sites Nuclear Safety Culture Monitoring Panel and
Safety Culture Leadership Team programs and activities by reviewing PNPSs Safety
Culture Monitoring procedures; reviewing Nuclear Safety Culture Monitoring Panel
meeting minutes for meetings conducted between October 2014 and December
2016; reviewing Safety Culture Leadership Team meeting minutes for meetings
conducted in March and June of 2016; performing interviews with the Nuclear Safety
Culture Monitoring Panel Chairman, Director of Recovery, and various department
managers; observing a monthly Nuclear Safety Culture Monitoring Panel meeting;
and conducting focus group discussions with PNPS personnel.
PNPS used procedure EN-QV-136, Nuclear Safety Culture Monitoring, to establish

the Nuclear Safety Culture Monitoring Panel and monitor trends in nuclear safety
culture. The NRC team observed a Nuclear Safety Culture Monitoring Panel
meeting on December 8, 2016, and identified that the panel members review of
Enclosure
182
information was less critical than may be necessary to result in an effective analysis
of the sites safety culture traits. For example, the panel members were provided
with summaries of recent CRs that included statistical trends prior to the meeting, but
did not appear to refer to the data sheets during the discussion and rating of safety
culture traits. Rather, it appeared as if a few panel members selectively discussed
only a few CRs, and then recommended a rating and trend based on this sample.
By ignoring trending data and relying solely on subjective consideration of a few
choice CRs, the Nuclear Safety Culture Monitoring Panel implementation process is
vulnerable to missing trends or faint signals that could only be identified by
considering multiple CRs together. The NRC team concluded that a lack of
benchmarking of sites with a mature monitoring process, including observation of a
full Nuclear Safety Culture Monitoring Panel meeting, contributed to assessment
results that appeared to be overly subjective.
The NRC team also noted one instance where the panel did not rigorously question
all of the applicable safety culture aspects of the information presented to them.
Specifically, one of the agenda items was for a presenter to report on actions to train
and encourage workers in a department to use the corrective action program.
During discussions, the presenter noted that an individual had taken the initiative to
correct an industrial/vehicle safety concern, and categorized this as a success, even
though the issue was not placed into the corrective action program as required. The
Nuclear Safety Culture Monitoring Panel focused only on the workers initiative, and
did not discuss the corrective action program aspects of the issue, as well as the
impact it could have on the safety culture at the station.
The NRC team also identified that although the Nuclear Safety Culture Monitoring
Panel has been meeting monthly since January 2016, which was more frequently
than required by procedure EN-QV-136, the panel did not appear to be fully effective
at recognizing all safety culture trends. For example, in the June 23, 2016, meeting
minutes, the panel documented multiple indications of safety culture issues in the
radiation protection work group, including a possible chilling environment. In August
2016, additional information (i.e., results of an Ethics Hotline investigation, an
ongoing Employee Concerns Program investigation, and two CRs) became available
to the panel that indicated there may still be events impacting the safety culture in
the radiation protection department. The NRC team noted that the panel narrowly
focused on the results of the ethics investigation, and documented that the issue was
investigated thoroughly. The panel did not appear to give consideration to the
Employee Concerns Program investigation that was in process at the time. The
Employee Concerns Program investigation was not complete until November 2016,
and subsequent meeting minutes did not note that the panel revisited this issue. The
NRC team concluded the Nuclear Safety Culture Monitoring Panel did not
demonstrate a rigorous, consistent process for evaluating all available information
concerning PNPSs safety culture. This was a missed opportunity for the panel, and
the site, to recognize and mitigate a potential chilled work environment in the
radiation protection work group (See Section 7.8 of this report for further discussion).
The NRC team also noted a lack of scrutiny by the panel following a misposition of
ventilation associated with secondary containment isolation in February 2016. After
the panel requested more information about how human error contributed to the
event, a detailed report was provided to all panel members prior to the April 2016
meeting. The NRC team noted that the report states that time pressure induced by
Enclosure
183
procedural requirements and management was a contributing cause. The NRC

team also noted that none of the corrective actions addressed management-induced
time pressure. The minutes did not document any discussion of the report, that the
panel discussed or questioned that time pressure induced by management was a
contributing cause to the event, or that no corrective actions were in place to address
this issue. The NRC team noted that the April 2016 meeting minutes did document
an additional human performance error during a surveillance test. The panel did not
appear to consider the possibility that these two human performance errors,
occurring just two months apart, might have had similarities from which safety culture
trend information could have been gleaned. This was a missed opportunity, not only
to address the potential issue of time pressure imposed by management, but also to
compare and contrast two human performance issues to gather any potential trend
information.
The NRC team reviewed meeting minutes for the Safety Culture Leadership Team
meetings in March and June 2016. No other minutes were available for review, as
PNPS did not retain documentation from previous Safety Culture Leadership Team
meetings. The NRC team noted that the Safety Culture Leadership Teams
discussions and conclusions were consistent with the data provided by, and the
recommendations from, the Nuclear Safety Culture Monitoring Panel.
In summary, the NRC team concluded that the processes and procedures used to
implement the Nuclear Safety Culture Monitoring Panel and Safety Culture
Leadership Team were appropriate. However, the NRC team determined that the
panel may not always be reviewing information with sufficient rigor such that
potential impacts on safety culture at the station can be identified and addressed.
Entergy documented these observations in CR-PNP-2017-01249 and CR-PNP-
2017-01250.
7.7 Nuclear Safety Culture Assessments and Third Party Independent Assessment
The NRC team evaluated the Third Party Nuclear Safety Culture Assessment report
to determine whether: 1) the associated assessment was comprehensive; 2) the
assessment methodology was sound; 3) the assessment team members were
independent and qualified; 4) the data collected supported the conclusions derived
from the assessment; and 5) PNPSs corrective actions in response to the
assessment findings were appropriate.
In addition to the Third Party Nuclear Safety Culture Assessment, the NRC team
reviewed the results of PNPSs independent safety culture surveys conducted in
2015 and the Integrated Nuclear Safety Culture Assessment Report. The Integrated
Nuclear Safety Culture Assessment Report integrated results from the 2015 safety
culture survey and 2016 Third Party Nuclear Safety Culture Assessment, and
mapped the findings to the fundamental problems and corrective actions in the
Comprehensive Recovery Plan. The NRC team also reviewed CR-PNP-2016-
Enclosure
184
04261, which documented corrective actions taken in response to the Integrated

Nuclear Safety Culture Assessment Report. Finally, the NRC team reviewed results
from the first periodic safety culture survey conducted by a third party vendor in
December 2016, in order to evaluate whether more recent survey results indicated
improving trends in safety culture.
The NRC team concluded that the Third Party Nuclear Safety Culture Assessment
was comprehensive and provided appropriate indications of the safety culture that
existed at PNPS at the time of the assessments in 2015 and 2016. The members of
the Third Party Nuclear Safety Culture Assessment team were independent from
PNPS and had appropriate qualifications to conduct the assessment. The Third
Party Nuclear Safety Culture Assessment used multiple data collection methods,
which consisted of reviewing results from the 2015 and 2016 independent safety
culture surveys, performing document reviews, observing meetings and work
activities, and conducting focus group discussions and individual interviews with
PNPS personnel and long-term contractors at the station. The response rate for the
2016 independent safety culture survey was 86 percent with 35 percent of the
respondents (191 of 650) providing written comments. The write-in comment
participation rate doubled in comparison to the 2015 assessment and was equal to
the industry average as typically observed by this Third Party Nuclear Safety Culture
Assessment Team. This was a large enough sample to provide confidence that the
survey results accurately reflected the safety culture perceptions at the site.
For the Independent Nuclear Safety Culture Assessment Review, PNPS formed a
team of internal personnel and external consultants to review and consolidate the
results from the 2015 independent safety culture survey and the 2016 Third Party
Nuclear Safety Culture Assessment into a set of problem descriptions. The
Independent Nuclear Safety Culture Assessment Review identified seven site
organizations requiring priority attention based on the safety culture assessment
results, and 17 descriptions for topical areas that should be addressed by safety
culture improvement efforts.
Attachment B of the Independent Nuclear Safety Culture Assessment Review

outlined how each of the safety culture topical areas were being addressed by
corrective actions associated with other fundamental problems in PNPSs
Comprehensive Recovery Plan or through corrective actions related specifically to
that particular topical area. The Independent Nuclear Safety Culture Assessment
Review identified a reasonable set of safety culture topical areas to be improved,
which resulted in new corrective actions beyond those already identified within other
fundamental problems. These corrective actions are documented in CR-PNP-2016-
04261, Nuclear Safety Culture Assessment.
The NRC team concluded that the Third Party Nuclear Safety Culture Assessment
was of sufficient quality to identify weaknesses in PNPSs safety culture and facilitate
the development of corrective actions. The NRC teams graded safety culture
assessment found that, in some instances, the results from the Third Party Nuclear
Safety Culture Assessment were not substantiated by results of focus group
discussions. For example, though the Supply Chain organization was noted as a
priority organization in the Third Party Nuclear Safety Culture Assessment, results of
Enclosure
185
interviews and focus groups did not support those conclusions. The Third Party
Nuclear Safety Culture Assessment write-in comments supported an environment
with anxiety with respect to the impending plant shutdown and may have affected
results at that point in time. In addition, the NRC team noted a potential weakness
with PNPSs planned monitoring tool, as discussed below.
CR-PNP-2016-04261 includes corrective actions for eight topical areas that were not
directly addressed by a fundamental problem or problem area, as well as corrective
actions for the seven priority outlier organizations noted in the Third Party Nuclear
Safety Culture Assessment. The NRC team determined that some of the corrective
actions documented in CR-PNP-2016-04261 to address some of the priority
organizations may not be effective in sustaining behavior changes necessary to
move safety culture forward at the station. For example, actions to address one of
the outlier organizations with decreasing trends in the safety culture surveys
included:
A meeting and read-and-sign document to discuss the survey results
An email containing a guide for how to track and follow issues in the
corrective action program
Development of a weekly look-ahead tool and scheduling a weekly look-

ahead meeting to ensure the department was kept informed of major work
and activities
Development of a one-time briefing to other departments in order to foster

communications between those departments
Noting that changing behaviors and attitudes affecting safety culture are long-term
actions that require providing expectations, training, if appropriate, continuous
positive reinforcement, and accountability, there appeared to be elements lacking in
the actions taken to move the radiation protection department in a positive direction
with respect to trust between management and technicians as well as between in-
house technicians and contractors. Results from the focus groups conducted by the
NRC team indicate that some individuals feel that there are still respectful work
environment issues, and as such, these actions may not have been effective. In
addition, focus group input resulted in a potential safety conscious work environment
issue within this workgroup (see Section 7.8 of this report). The actions taken
appear to be mainly focused on the short-term, and do not necessarily address the
potential work environment issues. Discussions with PNPS management about this
observation with respect to the long-term results of actions taken resulted in the
issuance of EFR corrective actions for each priority organization (CR-PNP-2016-
04261, CAs-84 91) to assess progress in these organizations and adjust actions as
warranted based on the results of those EFRs. The NRC team concluded that this
will be an important monitoring tool to maintain focus on improvements in these
priority organizations.
Enclosure
186
7.8 Other Observations
While onsite, the NRC team was made aware of several precursors to a potential chilled
work environment in the radiation protection department. During focus groups, the NRC
team learned of an Ethics Hotline incident perceived by workers as punitive; specifically,
an individual had been removed from duty and denied site access while Entergy
investigated a hotline allegation. The allegation was not substantiated and the individual
returned to work without loss of pay or punishment. Some focus group participants
indicated that there was stress and uncertainty in the department during the investigation
period in that most felt that the affected worker had been punished for doing his/her job,
and that if they raised a similar concern, they may also be subject to the same actions.
While nearly all radiation protection focus group participants stated that they would still
find an avenue to raise a concern, such as writing a CR or making a complaint to the
Employee Concerns Program, a few still felt that they might get punished if they
questioned the wrong person during the course of performing their duties.
The NRC team determined that the station had some opportunities to recognize the
impact this issue had on safety culture at the station. As discussed in Section 7.4 of this
report, PNPS should have conducted an Executive Review Board related to this action
to ensure that the action did not create a chilling effect in the affected workgroup and/or
other workgroups on site. Another opportunity would have been review by the Nuclear
Safety Culture Monitoring Panel, as discussed in Section 7.6 of this report. Finally, the
NRC team determined that the station had an additional opportunity to recognize the
impact this incident had on safety culture during the associated Employee Concerns
Program investigation and follow-up. The NRC team reviewed the Employee Concerns
Program case report and found anecdotal indications pointing to safety culture
weaknesses or areas of improvement, such as employee frustration with the corrective
action program, and personnel stating that this was bordering on a safety conscious
work environment issue during interviews. Additionally, though the Employee Concerns
Program report stated that monitoring would occur to ensure that the safety conscious
work environment conditions did not deteriorate, as of this inspection, the NRC team
found no evidence of any actions taken, or plan for future actions, to monitor the safety
conscious work environment in the radiation protection department.
Based on a review of this information, the NRC team determined that this issue is a
precursor to a potential chilled work environment in the radiation protection department;
a chilled work environment does not currently exist in this or any other department as a
result of this issue. Nearly all radiation protection focus group participants indicated that
they would still raise safety concerns through other available avenues, including the
corrective action program and the Employee Concerns Program. However, the NRC
team did conclude that this example illustrated a vulnerability in PNPSs monitoring of
safety culture at the station. Though several programs and processes are in place to
accomplish this task, each of those programs were working in isolation.
8. Performance Deficiency Cause Analysis
Per IP 95003, Section 3.10, the purpose of the performance deficiency cause analysis
was to provide a diagnosis of the principle causes for the decline in performance as well
as a prognosis for future improvement. This section also stated that the NRC may
perform a collective risk assessment of multiple separate or independent findings that
overlap in time to gain an understanding of the aggregated or collective risk profile.
Enclosure
187
The NRC team considered the collective risk impact associated with the findings
identified during this inspection. The NRC team determined that it was appropriate to
only consider the finding related to the A emergency diesel generator gearbox (Section
6.7.4.1) since it was the only finding that represented an actual loss of design function.
The detailed risk evaluation associated with this issue is documented in Attachment 1 of
this inspection report.
Additionally, the NRC team reviewed all of the root and apparent cause evaluations
conducted by PNPS during this analysis. The NRC team also considered the results of
the PNPS Third Party Nuclear Safety Culture Assessment and the NRC Independent
Safety Culture Assessment (Section 7.2).
Per PNPSs recovery process, the fundamental problems were categorized as those that
drove performance at PNPS, and the problem areas were those that were driven by the
fundamental problems. As discussed previously, PNPS identified three fundamental
problems and six problem areas. In general, the NRC team agreed with the
fundamental problems and problem areas identified during PNPSs recovery
evaluations. However, the NRC team noted the following areas of concern during the
inspection, which will need to be addressed by Entergy.
Weaknesses in Adequacy and/or Implementation of CAPRs
In general, the NRC team noted that Entergy exhibited weaknesses in the adequacy
and/or implementation of the CAPRs for the root causes reviewed during this inspection.
Specifically:
Corrective Action Program Fundamental Problem Root Cause Evaluation: The

NRC team noted that the root cause focused on the station senior leadership and
failed to adequately address the role that lower-level leaders had in
implementation in the day-to-day prioritization and resolution of corrective action
program items. The NRC team determined that the definition of leaders
associated with the root cause was too narrow and failed to recognize that
department performance improvement coordinators had a significant leadership
role in the implementation and assessment of the corrective action program.
This was evident in the NRC teams review of the associated CAPR, which
revealed that the department performance improvement coordinators and the
Performance Improvement Review Group members were absent from the CAPR,
or the supporting corrective action mentoring/coaching function. Instead, it was
described that these individuals would receive trickle down mentoring/coaching
from their respective department directors. Through interviews, the NRC team
verified that PNPS implemented no systematic or structured coaching/mentoring
to reach all station personnel with leadership responsibilities in the
implementation of the corrective action program. (Section 5.1.4)
September 2016 Feedwater Regulating Valve Failure Root Cause Evaluation:

During review of the root cause evaluation and associated CAPR, the NRC team
could not reconcile how revising an already adequate informational use
procedure, which was not understood, or creating a new site-specific procedure
that mirrored the requirements of EN-FAP-WM-011, which was also going to be
informational use based on interviews, would ensure that planning personnel
Enclosure
188
would always know and understand work order planning standards. Additionally,
the NRC team noted that Entergys planned corrective actions did not ensure that
new planners would be aware of the operating experience associated with this
event and did not revise any initial or create any planner refresher training
requirements, which could reasonably result in repetition of the issue. (Section
5.3.3)
Nuclear Safety Culture Fundamental Problem Root Cause Evaluation: In some

cases, the NRC team was not able to clearly link the causal factors identified in
the root cause evaluation to the CAPRs. Additionally, the NRC team determined
that there were multiple significant weaknesses associated with Entergys
implementation of the Targeted Performance Improvement Plans, which were
intended to ensure that Pilgrim leaders are held accountable to improving
performance associated with identified gaps in behaviors that demonstrate a
healthy nuclear safety culture. Examples of weaknesses identified by the NRC
team include parallel implementation of the plans, insufficient duration of
corrective actions to improve of behaviors, generic versus specific counseling to
address adverse behaviors, success criteria that would not be expected to result
in substantial performance improvement at the station, and a substantial number
of administrative issues. The NRC team concluded that these significant
implementation weaknesses severely limited the overall effectiveness of the
CAPR. The NRC team also noted that the Targeted Performance Improvement
Plans were a part of the CAPR for the Decision-Making/Risk Recognition
Fundamental Problem. (Section 7.1.4)
Operations Department Standards
As discussed in Section 4.7, the NRC team identified that Entergys conclusions and
assumptions throughout the SRV root cause evaluation were incorrect, which directly
affected the results of the analysis. Specifically, the station concluded that the CR
written for the A SRV in 2013 did not have enough information to appropriately identify
and evaluate A SRV performance. The station also concluded that one of the
contributing causes was inadequate operator fundamental training, as it relates to the
use of the steam tables, and management oversight of the corrective action program
and operability determination process. Based on a review of the CR, interviews with
those involved in the event, and review of Entergys interview records, the NRC team
concluded that there was enough information in the CR such that a knowledgeable
senior reactor operator could reasonably conclude that the A SRV did not open in 2013.
Further, the NRC team determined that the shift manager that approved the associated
operability evaluation possessed adequate training and knowledge to ensure an
adequate operability evaluation was completed. Thus, the NRC team concluded that the
cause of the incorrect and inadequate operability determination related to the A SRV
was associated with inadequate shift manager operability determination review rigor and
any associated causal factors.
As discussed in Section 6.3, during the recovery evaluations, Entergy identified a

standards performance deficiency related to performance of operability determinations
and functionality assessments. The NRC team concluded that identification of this area
as a standards performance deficiency was appropriate. Based on a review of the
apparent cause evaluation and associated corrective actions, the NRC team determined
that Entergy has made significant improvement in the application and implementation of
Enclosure
189
the operability determination and functionality assessment program. However, the NRC
team also concluded that Entergy continues to have some issues with the program that
are rooted in technical rigor and teamwork with the engineering department.
Given the NRC teams findings related to the SRV root cause evaluation and
implementation of the operability determination program, as well as station performance
during past events (e.g., NRC Inspection Report 05000293/2015007), the NRC team
adjusted the IP 95003 inspection plan during the onsite weeks to include additional
focused inspection of the operations department (Section 6.4) to ensure that Entergy
had not missed a fundamental problem or problem area related to operations
performance at PNPS. The NRC team concluded that in general, the operations staff at
PNPS can operate the plant safely, within design basis limits, and in a manner granted
to them in their license. However, numerous examples observed by both the NRC team
and the resident inspector staff indicated a lack of formality, appropriate technical
specification usage, and attention to detail for implementation of administrative
programs, which could represent precursors to a further decline in performance. The
NRC team determined that this was likely a result of inadequate management standards,
accountability, and expectations, as well as the operations staff having become
complacent with respect to conduct of plant operations over a number of years. Based
on observations conducted during the onsite weeks, as well as the results of this
inspection, the NRC team also determined that the operations department has not
consistently demonstrated strong site ownership, leadership, and high standards of
performance. Examples of this are ownership of equipment issues (e.g., A emergency
diesel generator radiator fan gearbox issue, Section 6.7.4), acceptance of operability
evaluation information with less than adequate technical rigor (Sections 6.3.4 and 6.3.5),
and behaviors in the main control room that are contrary to Entergy procedure EN-OP-
115, Conduct of Operations (Section 6.4).
The NRC team determined that additional actions will be needed by Entergy to fully
define the extent of the weaknesses related to operator standards at PNPS, as well as
develop appropriate corrective actions to address those weaknesses.
Implementation of Subject Matter Experts at PNPS
Entergy identified the following root causes during their IP 95003 recovery process at
PNPS:
Corrective Action Program Fundamental Problem: (Section 5.1) PNPS leaders

have not fostered a sufficient change to the organizational culture that is needed
to improve and sustain corrective action program performance. As a result, the
station continues to experience longstanding corrective action program shortfalls.
Decision-Making/Risk Recognition Fundamental Problem: (Section 6.1) Station

leadership has not consistently exhibited behaviors that set the requisite
standards and expectations for consequence-biased decision making and
effective operational risk management, consistent with a strong nuclear safety
culture. As a direct result, station leadership has not provided management
oversight and associated accountability to reinforce the proper expectations
regarding risk management. This root cause led to significant station events and
regulatory challenges at PNPS.
Enclosure
190
Nuclear Safety Culture Fundamental Problem: (Section 7.1) PNPS leaders have
not held themselves and their subordinates accountable to high standards of
performance. This reduced effectiveness of the performance improvement/
corrective action processes to recognize and stop the decline in nuclear safety
culture. As a consequence, the station has experienced long-standing problems
and increased regulatory oversight.
Based on a review of these root causes, the NRC team concluded that weaknesses in
PNPS leadership standards and behaviors were drivers for Column 4 performance at the
station. This is also supported by the results of the PNPS Third Party Nuclear Safety
Culture Assessment, which indicated that the senior leadership team had not been
consistently engaged in demonstrating and demanding higher levels and standards of
performance from the site. The NRC team reviewed station organizational charts and
noted that at the time of the inspection, there had been minimal changes in the stations
management organization since PNPSs transition to Column 4. Given this information,
the NRC team reviewed and assessed the CAPRs for each of these root causes to
determine whether these actions would be sufficient to correct leadership standards and
behaviors, and ensure sustained, improving nuclear safety performance to the planned
end of plant operating life in 2019.
As discussed in this report, the NRC team noted weaknesses in the adequacy and/or
implementation of the CAPRs associated with the corrective action program and the
Targeted Performance Improvement Plans. Specifically, the NRC team identified lack of
structured coaching and mentoring for all levels of leadership involved in implementation
of the corrective action program, and significant weaknesses in adequacy and
implementation of the Targeted Performance Improvement Plans, which were intended
to ensure that Pilgrim leaders are held accountable to improving performance
associated with identified gaps in behaviors that demonstrate a healthy nuclear safety
culture. Given these issues, the NRC team concluded that the subject matter experts
and mentors currently embedded in the PNPS organization currently play and will
continue to play a key role in improving and sustaining positive changes in safety culture
and performance at the station. This is especially true since it is commonly accepted
that safety culture takes on the order of years to change, and it is evident, based on the
observations and findings documented by the NRC team, as well as the NRC
independent safety culture assessment, that improved standards have not yet taken hold
across the entire organization.
Based on the results of this inspection, the NRC team concluded that the subject matter
experts and mentors appeared to have a positive impact on recovery efforts at PNPS.
However, the NRC team noted that with the exception of the lead corrective action
program subject matter expert and the Nuclear Safety Culture Advocate, who are
committed to the current end of plant operations, the station has the flexibility to remove
the subject matter experts and mentors following a successful EFR of the related area.
Also of note, the lead corrective action program subject matter expert was only required
to provide a minimum of one weekly on-site visit per month. The NRC team determined
that in general, the periodic reports provided by the subject matter experts contained
critical and constructive critiques of PNPS performance, along with recommendations for
improvement. These reports were a valuable tool in improving station performance,
provided that PNPS actively reviews and implements actions based on the
recommendations in the report. NRC team interviews and review of current corrective
action program items generated by the subject matter experts suggested that in some
Enclosure
191
cases, there may be an underlying level of resistance to these improvement

recommendations by some station managers (Section 6.1.3).
Given this situation, the NRC team determined that more robust and comprehensive
action is prudent related to implementation of the subject matter experts and mentors at
PNPS. At a minimum, this would include more significant time spent at the site,
objective evidence showing positive, timely actions taken in response to items identified
in the subject matter expert status reports, and addition of subject matter experts and/or
mentors at strategic levels in the operations department organization. Implementation of
subject matter experts and mentors should continue until a positive change in safety
culture is sustained and verified by NRC inspection. Ideally, implementation of the
subject matter experts and mentors would be upgraded to CAPRs and/or Category 1
Comprehensive Recovery Plan actions, if not already designated as such. Additionally,
more robust and comprehensive action is needed related to implementation of the
Targeted Performance Improvement Plans, as this action, in concert with the subject
matter experts and mentors, would be the foundation for improving the safety culture at
PNPS. Each of the weaknesses identified related to implementation of these plans
needs to be addressed and verified by NRC inspection.
9. Consideration of IMC 0305 Criteria
IMC 0305, Operating Reactor Assessment Program, Section 10.02e, provides

examples of unacceptable performance which represent situations in which the NRC
lacks reasonable assurance that the licensee can or will conduct its activities to ensure
protection of the public health and safety. The NRCs assessment of these examples of
unacceptable performance was as follows:
Multiple escalated violations of the facilitys license, technical specifications,

regulations, or orders.
The NRC determined that this criteria was not met, as multiple significant
violations (i.e., greater-than-Green for significance determination process
findings or greater than Severity Level IV for non-significance determination
process findings) had not occurred since Entergy started implementation of their
Comprehensive Recovery Plan actions at Pilgrim. This inspection report
documented one potential greater-than-Green violation related to the A
emergency diesel generator that is still under review. Specifically, the NRC was
aware of ongoing efforts by Entergy to further refine some of the key
assumptions used in support of the risk analysis, and plans to consider any
additional relevant information resulting from these efforts. Once this issue is
finalized, the NRC will determine its impact on the overall assessment of
performance at PNPS, and document the results of that review in an assessment
follow-up letter.
Loss of confidence in Entergys ability to maintain and operate the facility in

accordance with the design basis (e.g., multiple safety-significant examples
where the facility was determined to be outside of its design basis, either
because of inappropriate modifications, the unavailability of design basis
information, inadequate configuration management, or the demonstrated lack of
an effective Corrective Action Program).
Enclosure
192
This criteria was not met, as the NRC had not identified multiple safety-significant
examples where PNPS was determined to be outside of its design basis.
Entergy identified the corrective action program as a fundamental problem
(Section 5) and established corrective actions to address this area. Though the
NRC identified weaknesses in the CAPRs associated with the corrective action
program fundamental problem during this inspection, the NRC did not consider
PNPSs corrective action program to be ineffective. As mentioned previously,
once the issue related to the A emergency diesel generator is finalized, the NRC
will determine its impact on the overall assessment of performance at PNPS, and
document the results of that review in an assessment follow-up letter.
A pattern of failure of Entergy management controls to effectively address

previous significant concerns to prevent recurrence.
The NRC determined this criteria was not met. This was based on the NRCs
review of the three White inputs that resulted in PNPSs transition to Column 4.
The NRC noted that Entergy has not had a recurrence of an SRV failing to open
following issuance of the White finding on September 1, 2015 (ML15230A217).
The NRC also considered the trend of the performance indicators for unplanned
scrams and unplanned scrams with complications. The NRC noted that these
performance indicators are currently Green and have experienced a positive
and/or steady trend since the fourth quarter of 2015.
As documented above, the NRC concluded that Entergy exhibited weaknesses in

the adequacy and/or implementation of CAPRs, operations department
standards, and leadership standards and behaviors. While each of these items
could potentially represent precursors to recurrence of significant issues or
declining performance, they have not yet resulted in any risk-significant issues.
Additionally, Entergy had started implementation of their Comprehensive
Recovery Plan, as well as implementation of interim corrective actions to address
these issues.
As mentioned previously, this report documented one potential greater-than-

Green violation related to the A emergency diesel generator that is still under
review. Once the issue is finalized, the NRC will determine its impact on the
overall assessment of performance at PNPS, and document the results of that
review in an assessment follow-up letter.
Based on the above, the NRC determined that performance at PNPS did not warrant
transition to Column 5.
10. Licensee-Identified Violations
The following licensee-identified violations of NRC requirements were determined to be

of very low safety significance and meet the NRC Enforcement Policy criteria for being
dispositioned as non-cited violations.
10.1 Failure to Update Vendor Manuals
10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings,

requires, in part, that activities affecting quality shall be prescribed by documented
Enclosure
193
instructions, procedures, or drawings, and shall be accomplished in accordance with

those structures, procedures, and drawings. Entergy procedure EN-DC-148, Vendor
Manuals and Vendor Re-Contact Process, Revision 6, requires, in part, that the station
update vendor manuals every three years. Contrary to this, in July 2016, PNPS
determined through a self-assessment that they had 13 vendor manuals that had not
been evaluated for changes within 3 years. The NRC team determined that this finding
did not affect the design or qualification of a mitigating structure, system or component;
did not represent a loss of a system and/or function; did not result in loss of a train or two
safety systems greater than any technical specification allowed outage time; did not
result from an actual loss of safety function; and did not involve loss of any external
event mitigating system. Consequently, the NRC team determined that this performance
deficiency screened as having very low safety significance (Green). PNPS documented
this issue in their corrective action program as CR-PNP-2016-05115.
10.2 H2O2 monitors and Post Accident Sampling System out of Service
10 CFR 50.54(q)(2) requires, in part, that the licensee follow and maintain the
effectiveness of an emergency plan to meet the planning standard of 10 CFR
50.47(b)(4). Specifically, the licensee was to maintain the necessary equipment to
support the effectiveness of EALs. Contrary to these requirements, PNPS identified in
CR-PNP-2016-01491 that on three past occasions (March 15 through August 8, 2012;
September 4 through October 14, 2012; and June 4 through June 14, 2015) both trains
of the H2O2 monitors and the Post-Accident Sampling System were unavailable to
ensure the effectiveness of EAL 24, Deflagration concentrations exist inside PC, for the
potential loss of the containment barrier within the Fission Product Barrier category of
the EALs. This issue meets the criteria for very low safety significance (Green) because,
due to other EALs, an appropriate emergency declaration could have been made in an
accurate and timely manner.
11. Exit Meeting
On March 21, 2017, the NRC presented the inspection results to Mr. John Dent, Site
Vice President, and members of the PNPS staff, at a public exit meeting at the Plymouth
Memorial Hall in Plymouth, MA. The NRC verified that no proprietary information was
retained by the NRC team or documented in this report.
ATTACHMENT 1: DETAILED RISK EVALUATION

ATTACHMENT 2: SUPPLEMENTAL INFORMATION
Enclosure
A1-1
Pilgrim Nuclear Power Station
A Emergency Diesel Generator Cooling Water System Degradation
Detailed Risk Evaluation
Conclusion:
The total increase in core damage frequency (CDF) for the performance deficiency related to
the degraded cooling system was estimated to be Preliminary Greater than Green, a finding
with greater than very low safety significance. The calculated conditional risk increase is
dependent on the assumed fault exposure time, assumption of emergency diesel generator
cooling failure, credit considered for FLEX implementation and is dominated by external events
such as postulated fires within the B 4KV switchgear room. Based on an initial best estimate
assumption that the degraded cooling system would fail the function of the A emergency diesel
generator, the assumed exposure time, and an appropriate consideration of the risk mitigation
provided by the FLEX strategies, the upper bound for the CDF associated with this performance
deficiency was determined to be 7.2E-5 (i.e., of substantial safety significance or Yellow).
The NRC recognizes that there may be some uncertainty associated with the primary
assumptions relied upon in this risk analyses and the impact of any of these potential
uncertainties would be to lower the calculated CDF. Nevertheless, based on available known
information, the NRC has characterized the significance of this performance deficiency as
Preliminary Greater than Green. At the conclusion of the period, the NRC was aware of on-
going efforts by Entergy to further refine some of the key assumptions used in support of the
risk analysis. Consistent with the normal process for finalizing the significance of an inspection
finding, the NRC plans to consider any additional relevant information that may be provided by
Entergy in support of the final risk assessment.
Assumptions:
1. Impact on Emergency Diesel Generator A (X-107A) Operation: The major assumption

is that with the integrity of the gearbox lost with the relief valve cap and setscrew
displaced a severe loss of oil within the box occurred and would impact the continued
operation of the gearbox to drive the 108 inch radiator fan to support engine cooling.
With the as-found loss of the majority of the oil (82% loss) and potential to impact the
gear driven oil pump, the assumption is that excessive heat would be generated,
potentially damaging the bearings or gears. There was no test data available at the time
of this evaluation to indicate the gearbox could support the emergency diesel generator
mission time with the loss of the closed cooling oil system integrity. The A emergency
diesel generator was assumed to fail under these conditions within the first hour;
however, the assumption of failure within an hour was not a critical assumption. The
ability to perform for its mission time of 24 hours is the critical assumption due to the
potential impact on risk for postulated external events such as fires in the B 4KV
switchgear room.
2. Exposure Time: The most influential assumption is the exposure time of the degraded
gearbox for the estimate of the risk increase for the degraded condition. A 233 day
exposure time was determined by summing the past surveillance test A emergency
diesel generator run times until an accumulated 24 hour run time was calculated. This
Attachment 1
A1-2
approach assumes there was no degradation of the external gear box relief valve during
standby conditions. The assumption is that an impact to the relief valve integrity could
only occur or be applied when the A emergency diesel generator was in operation.
While the exact mechanism of the insert (setscrew) backing off was not known, it could
be speculated that the lack of insert thread engagement, potential loss of capscrew
preload due to gasket degradation or other degradation mechanisms contributed to the
eventual backing off of the cap and setscrew (here-after referred to as the threaded
insert) and loss of oil system integrity over time. Therefore the assumption was that the
degradation of the gearbox was A emergency diesel generator run time dependent.
3. Common Cause: The gearbox modifications were performed in the early 2000
timeframe and the design is similar between both emergency diesel generators where
external cooling lines with relief valves were added. The performance deficiency relative
to the lack of identification of a new failure mechanism during the design review process
when viewed in the broader context, had the potential to impact the redundant
emergency diesel generator as well and therefore the potential for common cause failure
on emergency diesel generator B was assumed. The analyst noted this was not a
dominant contributor to the overall calculated increase in risk.
4. Recovery Credit for A Emergency Diesel Generator: Recovery credit for the assumed
failure of the A emergency diesel generator gearbox was not given based on the
postulated nature of the failure and the time that would be required for the repair and
restoration of the emergency diesel generator.
Standardized Plant Analysis Risk (SPAR) Model Changes invoked to calculate a best
estimate change in risk due to condition
To provide a more realistic assessment of the risk significance due to the performance
deficiency impacting the A emergency diesel generator run time performance, the
conditional risk assessment reduced the offsite power recovery failure probabilities from
the base case model to credit emergency diesel generator run time which had been
completed during the previous monthly surveillance tests. This increased the allowable
SPAR model offsite power recovery hours (allowing more time for recovery) to reflect
that a safety bus (A5) would have been powered for a period of time until the A
emergency diesel generator would have failed due to the condition. Each surveillance
test run time was added until the 24 hour run time was shown to have been achieved
going back to February 8, 2016. Therefore the assumed exposure time was determined
to be 233 days. The 233 day run time assumption was determined to be consistent with
Section 2.5 within the Risk Assessment Standardization Project (RASP) Handbook
Volume 1 Internal Events guidance which applies for degrading mechanisms which are
dormant when the component is in standby.
The dominant core damage sequences involve loss of offsite power (LOOP) initiating
events with failure of the emergency diesel generators and the station blackout (SBO)
diesel generator. This results in a complete loss of alternating current (AC) power. Site
procedures direct the declaration of an extended loss of AC power (ELAP) by operations
staff within an hour and entering procedures involved with the FLEX mitigation strategies
in parallel with implementation of the appropriate emergency operating procedures. The
emergency diesel generator recovery failure probability was revised from a nominal 8 to
12 hours depending on the event sequence to 2 hours in the SPAR model to account for
Attachment 1
A1-3
the procedural direction to strip the control power from the emergency diesel generators
within 2 hours of declaring an ELAP. This was assumed to impact the potential recovery
of the B emergency diesel generator. The intent of the ELAP procedure step is to
lengthen the battery life to support reactor core isolation cooling and high pressure
coolant injection performance along with the ability to use the safety relief valves to
depressurize the reactor.
The SPAR model was revised specifically for SBO sequences. The model was revised
to remove the automatic failure of the reactor vessel depressurization, diesel driven
firewater low pressure makeup, and containment venting functions. These mitigating
functions were replaced with best estimate fault trees given the event sequences. The
model revision credited the detailed battery stripping procedures. The ability to
depressurize using the safety/relief valves (SRVs) is enhanced because there would be
more time available for the batteries to support this function. The procedural strategy
reviewed utilizes the SRVs to depressurize the vessel to remain below the heat capacity
temperature limit which would be approached in the torus at about 7 to 8 hours into an
SBO event. Depressurization would allow the diesel driven firewater pumps (low
pressure injection source) to be available for a few hours to fill the vessel as vessel
inventory is lost through decay heat and depressurization, delaying time to core boil-off.
The containment venting function was determined to be manually achievable even with
loss of power and was credited with a new fault tree. SPAR-H calculations for manual
operator actions were used to develop best estimate values for failures for each of the
above mitigating strategies. Finally, credit to manually close 4KV breakers without
control power (if offsite power is recovered) was considered through the 23KV line as
this was reviewed as being a viable recovery action for up to 16 hours following a SBO
event. Entergy supplied a thermal hydraulic analysis which was reviewed by the analyst
in crediting several hours of additional time to core uncovery after SRV closure on loss
of DC power. At this point the diesel driven firewater pumps could not inject as the
reactor would re-pressurize to the SRV mechanical setpoint. The intent was to account
for the time for core boil-off at the mechanical set pressures of the SRVs with no
injection available. This change was reflected by increasing the allowable time to
recover offsite power from 12 hours to 16 hours in various sequences.
Basic Event Changes The following basic events were incorporated based on best
estimate SPAR-H calculations for the appropriate SBO sequences:
Depressurization (ADS-XHE-XM-MDEPRLT, 2E-3), SPAR-H based on high stress all

other nominal conditions for blackout sequences;
Diesel Driven Firewater (FWS-XHE-XM-ERRLT, 1.2E-2), SPAR-H based on nominal

time, high stress, moderately complex due to potential changing reactor
backpressure conditions and manual re-alignments which may be required,
experience low;
Containment Venting (CVS-XHE-XM-VENTLT, 6E-2) in place of 0.3 which is

referenced in existing Pilgrim SPAR model change sets. SPAR-H based on nominal
time, high stress, nominal complexity, experience low, ergonomics poor as
potentially hot local conditions relative to required manual actions.
Attachment 1
A1-4
Internal Event Conditional Risk
Internal Risk was calculated for each period between surveillance test runs. The offsite power
recoveries were adjusted to reflect credit for the proven emergency diesel generator run time
going back to the satisfaction of a 24 hour mission time.
Internal Risk for Exposure Period
Calculated A emergency diesel generator run times during surveillance tests
Interval Dates Duration Runtime Cumulative Emergency

(days) (hours) run time Diesel Generator
(hours) Run Time
(hours)
1 8/31/16 to 28 0 0 0
9/28/16
2 7/26/16 to 36 1.9 1.9 2
8/31/16
3 6/27/16 to 29 2.3 4.2 4
7/26/16
4 5/31/16 to 27 2 6.2 6
6/27/16
5 4/26/16 to 35 2.6 8.8 9
5/31/16
6 3/28/16 to 29 2.5 11.3 11
4/26/16
7 3/1/16 to 27 2.9 14.2 14
3/28/16
8 2/8/16 to 22 2.3 16.5 17
3/1/16
9 1/25/16 to 14 18.4 34.9 24
2/8/16
The first interval assumed less than an hour run time during a postulated LOOP due to
the as-found 82% loss of oil in gearbox. The analyst noted test data did not exist to
justify success of the cooling function for the as-found degraded configuration. For
simplicity run time hours were rounded up or down to match offsite power non-recovery
basic events.
An 18 hour run was conducted on the emergency diesel generator during a test that
occurred on February 8 9, 2016. As a result, it was determined that the last time the
A emergency diesel generator could complete its 24 hour mission was on February 8,
2016. This represented a 233 day exposure time.
Internal Risk Increase Calculation Given Assumed Conditional A Emergency Diesel

Generator Failure
The analyst worked with Idaho National Labs to incorporate a best estimate revision to the
event trees and fault trees involved with SBO scenarios. This was performed to credit and/or
acknowledge equipment capabilities in the field including expected operational strategies based
Attachment 1
A1-5
on procedures and operator manual actions. The revised model also incorporated post-
processing rules to adjust the recovery factors for offsite power to credit that the A emergency
diesel generator had run multiple times successfully during previous surveillance testing.
Average test and maintenance for basic events was assumed over the assumed exposure
period.
Each surveillance testing run was credited to increase the time available to recover offsite
power before core boil-off would occur. The intervals between surveillance tests were broken
up to calculate the increase in risk between test intervals until the 24 hour mission was proven.
INTERNAL RISK CALCULATION

Interval Cumulative Base Cond. Delta Exposure Delta
Emergency Case/Yr * Case/Yr CDF/yr days CDF/interval
Diesel Generator
run time
1 0 6.71E-7 4.56E-6 3.89E-6 28 2.98E-7
2 2 6.84E-7 4.39E-6 3.71E-6 36 3.66E-7
3 4 6.84E-7 4.25E-6 3.57E-6 29 2.84E-7
4 6 6.84E-7 4.15E-6 3.46E-6 27 2.56E-7
5 9 6.84E-7 4.08E-6 3.39E-6 35 3.25E-7
6 11 6.84E-7 4.07E-6 3.39E-6 29 2.69E-7
7 14 6.84E-7 4.07E-6 3.39E-6 27 2.51E-7
8 17 6.84E-7 4.07E-6 3.39E-6 22 2.04E-7
2.26E-6/yr
*Base Case for 1st interval slightly different using SPAR model Events & Condition
Analysis (ECA) method resulted in no significant change
Increase in CDF/yr for 233 day exposure time = 2.26E-6/yr
The conditional internal risk increase due to the performance deficiency was dominated by the
Initiating Event LOOP weather-related, with a failure of the B emergency diesel generator to
run, a failure of the SBO diesel generator to run, failure to recover an emergency diesel
generator within 2 hours, failure to recover offsite power within 16 hours, with convolution factor
applied.
Secondary sequences included a LOOP weather-related initiating event with failures to properly
align and start the SBO diesel generator along with the B emergency diesel generator being in
test and maintenance conditions.
The dominant internal event sequences were SBO related loss of all AC sequences with
subsequent core damage.
In accordance with guidance within the RASP Volume I for determining exposure time this
includes the time the equipment remained out of service until repaired and available.
REPAIR TIME Internal Event Estimate
The best estimate repair time was gathered from the following information:
The technical specification limiting condition for operation was entered at 08:15 on 9/28/16 for
pre-start A emergency diesel generator checks (fuel rack tripped). The leak was found at
Attachment 1
A1-6
08:20 9/28/16. The emergency diesel generator run after repairs was completed at 00:45 on
9/29/16 and the limiting condition for operation exited after senior reactor operator review at
02:00 on 9/29/16. The analyst used the actual repair time of 18 hours which resulted in
negligible internal event risk increase as compared to the assumed exposure time for internal
events.
Therefore the results of the internal event analysis using a modified SPAR model yielded an
estimate in the increase in core damage frequency of 2.3E-6/yr for an assumed 233 day
exposure period.
External Events
The analyst reviewed the Individual Plant Examination of External Events for PNPS and
concluded that the only external events that had notable impact for this performance deficiency
were seismic and fire.
Seismic. A postulated seismic event could result in a long-term demand for the station
emergency diesel generators and/or SBO diesel generator if the seismic event was large
enough to damage the switchyard insulators causing a non-recoverable LOOP. The seismic
events of concern were those that would cause a LOOP but not a loss of emergency diesel
generator supplied buses. Based on the RASP Handbook Volume II for PNPS, the seismic
frequency which will cause a LOOP is 3.25E-4/yr. This value was substituted into a change set
and the internal initiating event LOOPGR was used as a surrogate to evaluate the increase in
risk. A change set was used for both a base case and condition case with the A emergency
diesel generator set to TRUE. The LOOPGR basic event was set to a probability of 1.0.
Additionally, offsite power recovery was failed for the relevant sequences in both the base case
and condition case.
The calculated increase in CDF was determined by multiplying the delta Conditional Core
Damage Probability (CCDP), condition case minus the base case, by the seismic frequency
causing a LOOP condition. The increase in CDF was determined to be 1.11E-6/yr. A 233 day
exposure period reduced this value to a nominal 7E-7/yr.
Fire. The SPAR model for PNPS does not include fire external events. The performance
deficiency impacted the ability to cope with fire events that resulted in reliance of the A
emergency diesel generator. The dominant fire event would be a fire in the B switchgear room
impacting 4KV bus A6 since fires in this area have the potential to challenge the B emergency
diesel generator, offsite power via the startup transformer (X4) or unit auxiliary transformer (X-
3), and power from Bus A8 which is fed in parallel by either the shutdown transformer (X-13)
from the 23KV line or the SBO diesel generator. Smaller fire contributors included main and
startup transformer failures that resulted in a transient and challenged bus A8 and switchyard
relay house fires that challenged the startup transformer and 345KV ring bus air circuit
breakers. Buses A5 and A6 are the two safety-related 4KV buses fed by A emergency diesel
generator (X-107A) and B emergency diesel generator (X-107B), respectively.
Major Risk Contributor B 4kV A6 Switchgear
Due to the complexities of this fire area, Entergy contracted fire modeling support from a vendor
to model the conditions. The Region I analyst performed a site visit and utilized the insights
from IMC 0609, Appendix F to understand the fire impacts in the high risk fire areas.
Additionally, the analyst interviewed operators and fire protection staff to understand and
Attachment 1
A1-7
evaluate the ability to mitigate the consequences of fires and evaluate recovery potential such
as FLEX strategies. From the walkdowns and modeling, fires in buses A6 (Train B safety-
related 4KV), and A2 and A4 (B switchgear room) were determined to be the most risk
significant. The area has fire detection but no fixed fire suppression. Cable type for fire
modeling was assessed as thermoset. The fire area also contains several additional ignition
sources such as 480 VAC switchgear, DC load centers, and battery chargers. These were
determined to be lesser contributors to the overall risk and were not specifically evaluated.
Since the main contributors were 4KV circuit breakers, three types of fire conditions were
evaluated, specifically, small electrical fires, large electrical fires, and high energy arcing faults.
For high energy arcing faults, fire modeling assumptions in IMC 0609, Appendix F, Attachment
5, Characterizing Non-Simple Fire Ignition Sources, were applied. Specifically, the zone of
influence extends 3 feet out and 5 feet above the source, the severity factor is assumed to be
1.0 and probability of non-suppression is also assumed to be 1.0. The high energy arcing fault
contribution was determined to be significant due to the large number of sources, damage
footprint susceptible targets, and lack of suppression.
The physical layout of the cable feeds from bus A8 (fed by SBO diesel generator or the
shutdown transformer) to safety buses A5 and A6 contributed significantly to the risk.
Specifically, the feed from bus A8 enters A6 switchgear at breaker 600. Power from A8 is then
routed through breaker 601 in A6 to feed A5 through breaker 501. Therefore, any fault that
impacts breakers 600 and 601 impacts the feed from the SBO diesel generator and shutdown
transformer (Bus A8) to bus A5.
Bus A6 contains 11 cubicles. These include feeds from B emergency diesel generator, offsite
power via the startup transformer and unit auxiliary transformer, and power from the 23KV line
via Bus A8. Based on the potential to damage the bus work it was assumed that a high energy
arcing fault in Bus A6 would result in the unrecoverable loss of the 23KV (Bus A8 feed), SBO
diesel generator, unit auxiliary transformer, startup transformer, and B emergency diesel
generator feeds. Since a fault on the supply side of the breaker is assumed either as the direct
cause or due to fire damage, this would also prevent offsite power from feeding Bus A5 (A train
safety-related 4KV). Evaluation of small and large fires in Bus A6 breakers was also evaluated.
Based on the fire size and location to various control power feeds, various off-site feed damage
states and recoveries were evaluated. For cases where recovery could be credible, a failure
probability of 0.1 was assumed. Although the manual operation of a 4KV breaker is not
complex, the actions would have to occur post-fire, possibly in the vicinity of fire damage. Given
this scenario, a 0.1 value seems appropriate for screening.
Bus A4 adjoins A2 and they are parallel to and six feet away from bus A6. There are 13 breaker
cubicles in A2/4. A bus duct connects A6 to A4. Two cable trays run between A2/4 and A6
approximately even to the tops of the switchgear. Control cables from A6 run in the tray closest
to A2/4. For a high energy arcing fault, these cables are in the zone of influence. Additionally,
small and large electrical fires originating in the cabinets have the potential to propagate and
cause cable damage. Based on the fire size and location to various control cables, various off-
site feed damage states and recoveries were evaluated. For recovery, a failure probability of
0.1 was assumed. Although the manual operation of a 4KV breaker is not complex, the actions
would have to occur post fire, possibly in the vicinity of fire damage. Given this as stated above,
0.1 seems appropriate for screening.
Attachment 1
A1-8
Figure 3 above is a simplified layout of the 4KV switchboards. The switchgear buses are shown
at an angle for simplicity of viewing. The actual installation in the field is with the switchgear
panels in a parallel configuration. Buses A2, A4, and A6 are located in the B switchgear room.
Buses A1, A3, and A5 are located in a room which is separated and above the lower switchgear
room. As stated above, Bus A4 adjoins A2 and they are parallel to and six feet away from bus
A6. The lower level in the above picture depicts a part of the B switchgear and Load Center
room which contains other equipment such as 125VDC, 250VDC, and 480V load centers along
with the 4KV buses.
The PNPS SPAR plant centered LOOP was used to approximate the baseline CDF for the
postulated fire event along with the conditional CDF. Offsite power recovery was not credited in
the model due to the postulated fire scenarios and equipment configuration and basic events
relative to offsite power recovery failure were set to TRUE. Fire frequency data was derived
from IMC 0609, Appendix F, Attachment 4, Fire Ignition Source Mapping Information: Fire
Frequency, Counting Instructions, Applicable Fire Severity Characteristics, and Applicable
Manual Fire Suppression Curves. As stated above, in cases where there was a potential for
recovery, the fire frequency was adjusted to reflect the recovery credit. The overall fire
frequency determined to impact offsite power, power from Bus A8, and the B emergency diesel
generator given the configuration of the buses was estimated to be 1.25E-4/yr.
Attachment 1
A1-9
For both the base case and condition case change sets were utilized in the SPAR model. The
base case used the LOOPPC initiating event as a surrogate for postulated fires in the B
switchgear room. The LOOPPC basic event was set to a probability of 1.0, with the A8 and A6
buses assumed failed (TRUE). Offsite power recovery was failed as well. The condition case
added the failure of the A emergency diesel generator (set to TRUE).
The conditional case CCDP was determined to be 0.934. The base case for a fire in this area
was calculated to be 4.5E-2. The delta CCDP was .934-.045 = .889
Delta CCDP (.889) x calculated ignition fire frequency related to B SWGR room (1.25E-4/yr) =
1.11E-4/yr
For a 233 day exposure, 1.11E-4/yr x 233/365 days) = 7E-5/yr estimated increase in CDF
From the above it can be seen that postulated fires related to the B 4KV switchgear were
determined to dominate the risk increase for this performance deficiency. With the assumed
condition of the A emergency diesel generator failure, the risk is dominated by the calculated
ignition fire frequency removing the capability of the A8 supply, offsite power, and B emergency
diesel generator.
Other Fire Areas of Interest
Main/Shutdown Transformer
A catastrophic failure of the main transformer would result in a plant transient and a potential
loss of Bus A8 due to exposure and direct fire impacts. Due to the proximity, and with the
transformer surge tank above A8, a severity factor of 1 was assigned. Due to the nature of the
fire, the probability of non-suppression before damage to A8 was assumed to be 1.0. In
addition to the main transformer fire, the A8 is also exposed to a shutdown transformer fire.
This transformer is energized but not normally loaded. An assumption was made that a fire
would lead to a plant transient due to smoke interaction/faulting across the main transformer
output lines resulting in load reject. Due to the nature of the fire, the probability of non-
suppression was conservatively set to 1.0. IMC 0609, Appendix F, table A4.1, lists the fire
frequency for outdoor/yard transformers for very large fires as 4.2E-3 per transformer. No
generic information was determined to differentiate between loaded and unloaded transformers.
Therefore the total Fire Ignition Frequency for the scenario was assumed to be 2 x (4.2E-3/yr) or
8.4E-3/yr.
The internal event PNPS SPAR model was used with the Transient initiating event as a
surrogate for this scenario. The base case and condition case used a change set with Transient
set to 1.0 and the loss of Bus A8 assumed. The condition case failed the A emergency diesel
generator. The delta CCDP of 1.01E-4 was multiplied by the frequency (8.4E-3/yr) to obtain
8.4E-7/yr. This was adjusted for credit for potential B emergency diesel generator recovery at
2 hours. The result was 6.7E-7/yr and when adjusted to 233 days the increase in CDF was
4.2E-7/yr. The dominant core damage sequence was a Transient (loss of power from unit),
failure of offsite power with no recovery, and a failure of the B emergency diesel generator to
run with failure to recover.
Switchyard Relay House

A fire in the 208V relay panel could impact the 345KV ring bus and startup transformer. The
internal cabinet fire estimated from IMC 0609, Appendix F, table A4.1, lists the fire frequency as
6E-5/yr for small general electrical cabinet fires. No high energy arcing fault sources were
Attachment 1
A1-10
identified in this room. The severity factor (SF) was assumed to be 1.0 for a fire originating and
contained within the associated cabinet. There is no automatic suppression and therefore the
probability of non-suppression (PNS) was assumed to be 1.0. The Event initiating frequency
was FF (fire frequency) x SF x PNS = 6E-5/yr.
The analyst used the internal event initiating event LOOPSC as a surrogate for the area. The
event was set to 1.0 with failure of offsite power recovery. The condition case added the failure
of the A emergency diesel generator. The delta CCDP (3.4E-3) x event initiating frequency
(6E-5/yr) = 2E-7/yr
For a 233 day exposure the increase in risk was calculated to be a nominal 1.3E-7/yr. The
dominant core damage sequence was an assumed loss of the unit auxiliary generator feed on
reject, LOOP, with failure of the B emergency diesel generator to run without recovery and
failure of the SBO diesel generator to run.
Large Early Release Frequency
For issues resulting in an increase in CDF > 1E-7, IMC 0609 requires an evaluation of Large
Early Release Frequency (LERF) using the guidance of NUREG-1765, Basis Document for
LERF Significance Determination Process, and IMC 0609, Appendix H, Containment Integrity
Significance Determination Process. The performance deficiency associated with the failure of
the A emergency diesel generator would be considered a Type A finding and, as such, the
calculated increase in CDF value is used in conjunction with an appropriate LERF factor
(multiplier) to determine the estimated increase in LERF associated with the issue. Per
Appendix H, Table 5.2, LERF factors of 1.0 or 0.6 are used for high pressure core damage
accident sequences with the drywell dry or flooded, respectively. These Appendix H LERF
factors are considered conservative bounding values. More recent insights from an NRC Office
of Research sponsored study by Energy Research, Inc. (ERI/NRC-03-04, November 2003) and
the State of the Art Reactor Consequence Analysis Project at Peach Bottom Nuclear Power
Station (NUREG/CR-7110) have identified that improved modeling and analysis of anticipated
types and sizes of reactor coolant system ruptures, projected containment heating and fuel-
coolant interactions, and operator actions taken in accordance with emergency operating
procedures significantly reduce the potential for containment breach and the likelihood of a large
early release. Furthermore, the dominant sequences discussed above would result in
considerable time before postulated core damage and potential containment breach. In the
absence of early core damage sequences for this condition, LERF was determined to not be a
significant risk contributor and the safety significance of this performance deficiency is defined
by the estimated increase in CDF.
Sensitivity Analyses
The analyst performed sensitivity runs showing the results for various scenarios altering some
of the assumptions:
The SPAR model ECA tool was used to check the sensitivity of several assumptions. This was
considered a valid tool because the effects of the reduction in risk due to crediting emergency
diesel generator run time was determined to not have a major impact on the risk determination
(less than 5%). The ECA was used for the sensitivity runs.
Sensitivities 1 and 2 were determined not to result in a large uncertainty to the calculated risk.
Attachment 1
A1-11
These sensitivity runs were applicable to the internal risk calculations and therefore did not have
a major impact as the fire risk from the B switchgear room dominated the total risk increase.
Sensitivity 1
Emergency Diesel Generator B recovery time not limited to 2 hours adjusted to 8

hours
An ECA run was performed to determine the difference in the increase in risk by
assuming an increased time allowance for an emergency diesel generator recovery
given the dominant internal event core damage sequences. Specifically, the SPAR
model for the redundant B emergency diesel generator recovery time allowance in the
SBO sequences was changed to 8 hours versus 2 hours and resulted in a conditional
increase in CDF of 1.54E-6/yr as compared to 2.3E-6/yr.
Sensitivity 2
Common cause not considered to be applicable

Assuming that common cause did not apply to this condition and the failure of the A
emergency diesel generator gearbox would have been an independent event from the
B emergency diesel generator resulted in a conditional increase in CDF of 1.93E-6/yr.
Sensitivity 3
Use and acknowledgment of FLEX strategy and equipment

This sensitivity was applicable to both internal and external events and can have an
impact on the determination of the best estimate calculated increase in risk. The analyst
for this sensitivity run built into the SPAR model a top event which considered that FLEX
strategies may be successful in reducing the calculated risk. The licensee indicated they
had FLEX procedures and equipment available at the site which would be utilized for the
dominant core damage scenarios. FLEX generators would be used to support re-
powering the selected safety DC buses as applicable and for FLEX designated low
pressure injection pumps to support core cooling.
The NRC at the time of this evaluation has not made a final decision on quantification of
the FLEX credit in the significance determination process analyses.
The analyst performed a review of the PNPS overall FLEX strategy studies along with
specific procedures for safety-related DC bus stripping and evaluated timing sequences
relative to implementing FLEX equipment. The analyst conducted several best estimate
sensitivity evaluations using a simplified semi-quantitative approach by turning on an
assumed FLEX recovery in the top event for the dominant SBO core damage event
sequences. This recovery was only turned on for the applicable sequences which the
FLEX strategy relies on. FLEX requires reactor depressurization for the low pressure
pumps, therefore when reactor depressurization would fail in an event sequence the
FLEX credit was not applied. Additionally, containment venting was assumed to have to
be successful in accordance with FLEX evaluations for this recovery to have been
turned on.
The first sensitivity run used a simplistic overall order of magnitude risk reduction, while
crediting the FLEX strategy. This was simply applied to the B switchgear room fire
scenario since it dominates the risk. This approach did not use the modified SPAR
Attachment 1
A1-12
model which applied FLEX recovery only for specific sequences. The below reviews
were conducted using assumed values for FLEX credit that have not been endorsed by
the NRC but are provided here strictly for the purpose of understanding some of the
potential impact of the assumptions on the overall risk reduction. The second and third
sensitivity analytical considerations use specific values for FLEX credit but were only
applied in the specific sequences of the model where FLEX credit would be appropriate.
A simplified 0.1 order of magnitude reduction

(Fire in the B switchgear room) Assuming the majority of risk was from SBO sequences
and an assumed overall FLEX failure probability of 0.1, resulted in an external event
increase in CDF of 7E-5/yr x 0.1 or 7E-6/yr. It is noted using a 0.1 reduction for fire
scenarios may be a non-conservative assumption given only one battery charger may be
available to re-power under these situations, and the remaining battery charger in the A
switchgear room above may have some complications due to the environment, smoke
etc. Notwithstanding this, using a nominal FLEX credit of 0.1 the combined estimated
increase in risk (internal and external would be in the High E-6/yr range.
Modified SPAR model with a top event FLEX recovery of 0.1 assumed
The estimated failure probability of FLEX was set to 0.1 for sensitivity analysis purposes
only. The modified SPAR model with the built in FLEX recovery only applies for
sequences where it was estimated it could be successful (i.e. depressurization
successful, containment venting successful, success of one of the high pressure
injection sources such as high pressure coolant injection or reactor core isolation cooling
where there likely would be time to set up equipment, etc.)
Turning on the FLEX recovery (0.1) for the conditional assessment for the B switchgear
room postulated fire event using the fire ignition frequency of 1.25E-4/yr resulted in an
estimated increase in CDF for 233 days of 1.1E-5/yr or a nominal 16% of the CDF
increase without FLEX credit. This number reflects that FLEX is not applicable to all of
the core damage sequences. This was applied for the external risk because it
dominates the risk increase. The same method would reduce the internal event risk as
well into the E-7/yr range. There are uncertainties with this application, because a fire
event would result in some personnel being devoted to the fire brigade, and smoke and
environmental factors may impact the ability to re-install power to the battery chargers
from FLEX equipment. However, it should be noted that the 7 month exposure time
does not recognize that for many months, the A emergency diesel generator would
have been likely successful for hours before failure such that the fire brigade would have
time to address the B switchgear room fire and the environment may become more
accessible given the amount of time the A emergency diesel generator would run
before failure.
Modified SPAR model with a top event FLEX recovery of 0.2 assumed
Using a 0.2 failure probability for the FLEX top event for the purposes of conducting the
sensitivity analysis only. Turning on the FLEX recovery (0.2) for the conditional
assessment, for the B switchgear room postulated fire event using the fire ignition
frequency of 1.25E-4/yr resulted in an estimated increase in CDF of 1.7E-5/yr for the 233
day exposure. (24 hour mission time)
Attachment 1
A1-13
Uncertainties
Due to the complexity of the analysis, uncertainties were not able to be captured. Sensitivity
runs were made to address uncertainty.
Qualitative Considerations
RASP Volume I guidance was used for an exposure time estimate. This utilizes the criteria of
proof of emergency diesel generator run times adding up to a 24 hour run time for the
emergency diesel generator mission. A qualitative consideration is that while the assumed
failure is being assessed as a run time failure, this assessment of a linear function for
degradation may be overly conservative. In other words, perhaps there could be some function
of degradation which is not linear with respect to run time which would reduce the exposure time
from 233 days.
Entergy has additional mitigation capabilities as required by 10 CFR 50.54(hh)(2) to deal with
losses of the plant due to large fires and explosions. B.5.B low pressure pumps may also be
available in the situation where they would need low pressure injection sources above and
beyond the diesel driven firewater pump and FLEX low pressure pumps. Additionally, PNPS
has B.5.B direction to utilize automatic depressurization system SRV battery carts, which can be
utilized to power 2 of the 4 SRVs according to interviews with the plant staff, outside of the
normal DC connections (B.5.B). This would allow an extension of time to ensure the reactor
remains depressurized.
Interviews with senior reactor operator staff indicate FLEX can be implemented in about 3.5 to
4 hours. In about 4 hours the 86kW Flex generator can be hooked up to power the 125VDC A
Battery Charger. The 150kW hook up would be used for the 125VDC B Battery Charger and
250VDC equipment and this is pre-staged in the turbine building. Therefore, for the dominant
fire scenario in the B switchgear, the 86kW Flex generator may still be available to hook up to
the A 125 VDC battery charger, and power the SRVs and reactor core isolation cooling system
controls. This would be dependent on the fire conditions, smoke, available resources, etc. This
could of course reduce the risk near an order of magnitude depending on credit given.
Decay Heat Considerations

Because the A emergency diesel generator was considered run time dependent, going back
several months in LOOP scenarios, or the fire scenario, the A safety-related loads would have
been maintained to remove decay heat and cool the torus until the A emergency diesel
generator would have failed. This would allow decay heat generation to be lower than that of a
LOOP which quickly leads to SBO conditions. This would extend the time available to develop
recovery plans for other postulated failures such as the SBO diesel generator or B emergency
diesel generator and extend time available to recover offsite power as it may take longer for
core boil off.
Competing Priorities
In the sequences that lead to core damage, failure of the A emergency diesel generator would
not be the only failure which would occur. Control room operators would have numerous
competing priorities which would complicate responses and recoveries. For example, operators
may also have to assist in offsite power restoration, B emergency diesel generator evaluation
and/or restoration, and SBO diesel generator evaluation and/or restoration if these components
failed. These competing priorities could increase uncertainties.
Attachment 1
A1-14
Emergency Planning
Dependent on the A emergency diesel generator failure and other component failures, the
Technical Support Center should eventually be staffed when required along with other
emergency preparedness personnel available to assist in the evaluation and recovery of
equipment.
Entergys Analysis
Entergys initial cause evaluation for the integrity failure of the A emergency diesel generator
gearbox closed oil system was inconclusive relative to the exact failure mechanism. The initial
conclusion was that either vibration may have caused the condition or an operator error, where
the relief valve may have been inadvertently loosened by operations staff. This would have
potentially impacted the capscrew and threaded insert, assuming there was confusion in where
the oil level needed to be checked. However, the team interviewed various operators who
displayed the proper knowledge of how they were to ensure proper gear box oil level and there
were no indications that operator error may have occurred. If operator error were to have
occurred, a different performance deficiency would exist, with a different exposure time and
different risk impact. Entergy, as of early April 2017, has not ruled out the potential for operator
error which would reduce the exposure time of the issue and relate to a different potential
performance deficiency. Additionally, Entergy had requested a vendor to assess the potential
failure mechanism relating to vibration in causing the degraded gearbox oil condition and will
make a final conclusion after their reviews are completed.
Entergy staff had verbally indicated, regarding only internal events, they obtained similar results
in the 2E-6/yr range for an increase in CDF for the 233 day exposure time used in the NRC
evaluation (without FLEX consideration.) The exposure time was from the NRC RASP
guidance relative to achieving a 24 hour mission time. This was not a final determination by
Entergy that they agreed with this exposure time but simply that they came out in the same risk
increase range using that assumption for internal events. Entergys external event risk increase
conclusion had not been provided as further evaluation is on-going.
Entergy stated they may pursue additional evaluations relative to the risk determination for this
issue. The licensee contracted for fire modeling of the B switchgear room along with various
other fire areas. The assumptions and analyses were reviewed by a senior reactor analyst from
Region I and was a major input to the external event risk analysis.
Lastly, Entergy has stated they may perform a detailed study on evaluating FLEX credit by
developing detailed fault trees and event tree sequences to further analyze the condition.
Model Data
For internal events and external events from fire and seismic, the analyst used the limited use
model for PNPS (February 17, 2017), Version 8.24, ran on SAPHIRE, Version 8.1.4. Truncation
at the 1E-12 level was used.
Attachment 1
A2-1
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Entergy Personnel
J. Dent, Site Vice President
J. MacDonald, General Manager of Plant Operations
S. Asplin, Service Water System Engineer
J. Barilaro, Mechanical Maintenance Planner
G. Blankenbiller, Chemistry Manager
A. Bouchard, Department Performance Improvement Coordinator
D. Burdick, Corrective Action Program Trending Subject Matter Expert
S. Burke, Fire Protection Engineer
D. Calabrese, Emergency Preparedness Manager
G. Cassell, Lead Facilities and Equipment Specialist
F. Clifford, Manager, Operations Support
E. Cobey, Senior Corrective Action Program Subject Matter Expert
R. Coolige, Senior Control Room Engineer
E. Cota, Mechanical Maintenance Coordinator/Scheduler
K. Coupland, Electrical Maintenance Coordinator/Scheduler
L. Cummins, Senior Maintenance Specialist
W. Deacon, Senior Maintenance Specialist
M. Dagnello, Fix it Now Team Specialist
P. Doody, Design Engineering, Senior Staff Engineer
K. Drown, Performance Improvement Manager
G. Flynn, Operations, Senior Manager
P. Gavine, Fix-it-Now Team Supervisor
J. Gerety, Systems Engineering Manager
P. Gerry, Performance Improvement, Site Operating Experience Coordinator
P. Gresh, Training, Senior Operations Instructor
R. Haislet, Operations, Shift Manager
J. Hendy, Operations, Licensed Operator
M. Hetwer, Operations, Shift Manager
C. Kearins, Operations Specialist
R. Kiley, Operations Specialist
P. Leavitt, Chemistry Supervisor
S. Ledyard, Recovery, Cause Evaluator
M. Lynch, Supervisor, EFIN Systems Engineering
J. Martin, Corrective Action Program Subject Matter Expert
J. McDonough, Operations, Control Room Supervisor
T. McElhinney, On-line Scheduling Superintendent
K. McGilvray, Senior Reactor Operator
A. Medeiros, Systems Engineering, Supervisor
C. Mell, Recovery, Cause Evaluator
R. Metthe, Senior Civil Engineer
D. Miller, Maintenance Coordinator
P. Miner, Nuclear Safety/Licensing Specialist
P. Moore, Predictive Maintenance Engineer
R. Morris, System Engineer
D. Mortimer, Operations Support, Department Performance Improvement Coordinator
K. Murphy, Training, Operations Instructor
Attachment 2
A2-2
B. Naeck, Senior Engineer

A. Notbohm, Performance Improvement, Corporate Functional Area Manager
D. Noyes, Recovery Director
J. ODonnell, System Engineer
J. Ohrenberger, Maintenance Manager and Decommissioning Director
P. ONeil, Corrective Action Program Subject Matter Expert
R. ONeil, Operations, Shift Manager
M. Pait, Training
J. Parmentor, Senior Emergency Planner
D. Perry, Recovery Manager
N. Reece, Senior Engineer
G. Riva, Recovery, Cause Analyst
M. Romeo, Regulatory Assurance and Performance Improvement, Director
F. Russell, Preventive Maintenance Engineer
J. Sabina, In-Service Testing Engineer
E. Simpson, Work Week Manager
J. Shumate, Production Manager
P. Smith, Operations Support, Consultant
K. Sullivan, Senior Emergency Planner
R. Swanson, Systems Engineering, Maintenance Rule Coordinator
R. Tessier, Operations Support, Mentor, Subject Matter Expert
M. Thornhill, ALARA Coordinator
J. Vincent, Instrumentation and Controls Coordinator/Scheduler
J. Webers, Operations, Control Room Supervisor
J. Whalley, Operations, Shift Manager
T. White, Engineering Manager
M. Williams, Licensing Specialist
K. Woods, Supervisor, Balance of Plant Systems Engineering
NRC Personnel
E. Carfang, Senior Resident Inspector, PNPS
C. Cahill, Senior Reactor Analyst, Region I
M. Gray, Branch Chief, Region I
B. Pinson, Resident Inspector, PNPS
J. Vazquez, Resident Inspector, PNPS (acting)
L. Brandt, Resident Inspector, PNPS (acting)
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
05000293/2016011-06 AV Design Change Not Appropriately Reviewed by Entergy
(Section 6.7.4.1)

Opened/Closed
05000293/2016011-01 NCV Failure to Identify All Root Causes of a Significant
Condition Adverse to Quality (Section 4.7)

Attachment 2
A2-3
05000293/2016011-02 NCV Failure to Establish Corrective Actions to Preclude

Repetition of a Significant Condition Adverse to Quality
(Section 5.1.4)

05000293/2016011-03 FIN Failure to Issue Appropriate Corrective Actions to
Preclude Repetition for the Causes of the September
2016 Scram (Section 5.3.3)

05000293/2016011-04 NCV Programmatic Issue with Implementation of the
Operability Determination Process (Section 6.3.4)

05000293/2016011-05 NCV Failure to Establish Corrective Actions to Address Scope
of Procedure Quality Issues (Section 6.5.4)

05000293/2016011-07 NCV Failure to Report Condition Prohibited by Technical
Specifications and a Safety System Functional Failure
(Section 6.7.4.2)

05000293/2016011-08 NCV Failure to Adequately Monitor the Performance of
Maintenance Rule Scoped Components (Section
6.9.4.1)

05000293/2016011-09 NCV Ineffective Corrective Actions to Address Conditions
Adverse to Quality Regarding Components in Contact
with or Close Proximity to the Drywell Liner (Section
6.9.4.2)

05000293/2016011-10 NCV Failure to Promptly Correct a Condition Adverse to
Quality for the Residual Heat Removal System (Section
6.9.4.3)

05000293/2016011-11 FIN Failure to Adequately Develop and Implement Targeted
Performance Improvement Plans (Section 7.1.4)
Attachment 2
A2-4
Table 1: Procedures with Quality Issues

Procedure Title Revision
1.3.4-1 Procedure Writers Guide 25
2.1.42 Operation During Severe Weather 0
2.2.125.1 Reset of Primary and Secondary Containment Isolations (Group I, 24
II, III, IV, V, VI, and VII)
2.2.2 Main Generator and Main Transformer 1
2.2.28 Plant Heating System 0
2.2.3 Startup Transformer 0
2.2.32 Salt Service Water System (SSW) 95
2.2.39 Turbine Building Heating, Cooling and Ventilation System 37
2.2.46 Control Room Cable Spreading Room and Computer Room 58
Heating, Ventilation, and air Conditioning System
3.M.2-10 Feedwater Control Valve Isolation and Maintenance 0
3.M.3-33 345KV Startup Transformer Calibration and Functional Relay 34
Testing
3.M.3-39 Turbine Generator Calibration of Relays, Lockout Test and 0
Associated Annunciator Verification
3.M.3-40 Relay House Protective Relay Calibration/Functional Test and 37
Remote Alarm/Local Annunciator Verification
3.M.3-47.1 A Train Functional Test of Individual Load Shed Components 0
3.M.3-57 ACB Air Tank Inspection 0
3.M.4-115 Traveling Water Screen Inspections 15
3.M.4-14.2 Salt Service Water Pumps; Routine Maintenance 68
7.2.34 Operation of Feedwater Sample Sink-C122 18
7.8.1 Water Quality Limits 0
8.7.4.8.5 H2/O2 Sample Entry Rack Panel Isolation Valve Position Indication 0
Verification
8.C.19 Main Transformer Surveillance 44
8.C.21 345 kV Breaker Weekly Surveillance 0
8.C.22 Startup Transformer & 345 KV Switchyard Surveillance 0
8.E.24.1 Switchgear Rm Emergency Ventilation Sys (SREVS) Instrument
Calibration and Functional Test 0
8.E.70 Main Generator Runback Functional Calibration 44

8.F.24.1 Reactor Building Heating, Ventilation and Air Conditioning (HVAC) 0
Instrument Calibration and Functional Test
8.F.6 Reactor Feedwater Instrument Calibration 0
8.M.3-14 H2/O2 Analyzer System Calibration 0
8.P.1 Determination of Optimum Operating Liquid Level for Feed Water 5
Heaters
8.P.8 Control Room Tracer Gas Testing for In-leakage 0
8.Q.2-3 H2/O2 Analyzer Panel Component Maintenance 0
Attachment 2
A2-5
LIST OF DOCUMENTS REVIEWED
Condition Reports
CR-HQN-2016-00767 CR-HQN-2016-01611* CR-HQN-2017-00049*
CR-PNP-2006-03712 CR-PNP-2009-01970 CR-PNP-2013-00867
Attachment 2
A2-6

Attachment 2
A2-7

CR-PNP-2016-09337 CR-PNP-2016-09340* CR-PNP-2016-09343
CR-PNP-2016-09368* CR-PNP-2016-09375 CR-PNP-2016-09376
CR-PNP-2016-09377* CR-PNP-2016-09380* CR-PNP-2016-09382*
CR-PNP-2016-09383* CR-PNP-2016-09389 CR-PNP-2016-09411*
CR-PNP-2016-09511* CR-PNP-2016-09526 CR-PNP-2016-09527
CR-PNP-2016-09530 CR-PNP-2016-09531* CR-PNP-2016-09540*
CR-PNP-2016-09552* CR-PNP-2016-09555* CR-PNP-2016-09563
CR-PNP-2016-09617 CR-PNP-2016-09621* CR-PNP-2016-09623*
Attachment 2
A2-8

CR-PNP-2017-02242*
Learning Organization Documents

LO-PNPLO-2013-00080 LO-PNPLO-2014-00063 LO-PNPLO-2014-00084
LO-PNPLO-2016-00004 LO-PNPLO-2014-00122 LO-HQNLO-2016-00029
Work Tracker Documents

LO-WTPNP-2016-72
CR-WTHQN-2013-0078, dated January 14, 2013, 2012/2013 ECP Self-Assessment
Recommendation
CR-WTHQN-2013-0128, dated January 24, 2013, Benchmark ECP Fleet Reporting to
Corporate Management
CR-WTHQN-2014-0219, dated March 10, 2014, actions from 2014 ECP assessment
CR-WTHQN-2015-0193, dated March 4, 2015, Actions in response to September 2014 ECP
Assessment
WT-WTPNP-2016-16, Dedicated Notification Network issues
Attachment 2
A2-9
Emergency Operating Procedures

EOP-1, RPV Control, Revision 14
EOP-2, RPV Control Failure to Scram, Revision 14
EOP-3, Primary Containment Control, Revision 11
EOP-4, Secondary Containment Control, Revision 12
EOP-11, Figures, Cautions and Icons, Revision 6
EOP-16, RPV Flooding, Revision 7
EOP-26, RPV Flooding Failure to Scram, Revision 6
Engineering Changes
33538, Replace RHR Total Flow Indicator FI-1040-1A with an Equivalent, Revision 0
52583, Setpoint Change for TE-1291-60A (RWCU Filter Area 74-ft Elevation, Revision 0
61828, Replace Screenwash Dechlorination Pump Event Recorder ER-3905, Revision 0
62362, Lower Ultimate Heatsink Alarm Setpoint from 73 F to 71 F, Revision 0
67111, Evaluate HPCI/RCIC Coupling And Use of Mobilux EP 111 Grease, Revision 0
67308, Update Vendor Manual V0636 with Vendor Contact Information, Revision 0
68225, Update Emergency Lighting Catalog Vendor Manual V1032 to Satisfy the Vendor
Manual Review, Revision 0
Procedures
1.3.142, PNPS Risk Review and Disposition, Revision 5
1.3.144, Maintenance Performance of Trip Sensitive Activities, Revision 4
1.3.145, PNPS Recovery Procedure, Revision 0
1.3.34, Operations Administrative Policies and Processes, Revision 141
1.3.4-1, Procedure Writers Guide, Revision 25
1.3.4-10, Writers Guide for Emergency Operating Procedures, Revision 13
2.1.12.1, Emergency Diesel Generator Surveillance, Revision 82
2.2.32, Salt Service Water System (SSW), Revisions 93 and 94
2.2.8, Standby AC Power System (Diesel Generators), Revision 115
2.4.16, Distribution Alignment Electrical System Malfunctions, Revision 46
3.M.3-24.15, Valve Stem Lubrication, Revision 11
3.M.4-78, RCIC Turbine Major Preventative Maintenance Inspection, Revision 12
3.M.4-79, HPCI Turbine Preventive Maintenance Inspection Critical Maintenance, Revision 19
4.01, Control, Issuance and Maintenance of Weapons, Revision 23
5.7.3.2, Drywell and Torus Atmospheric Sampling under Emergency Conditions, Revision 14
7.1.65, Manually Sampling Using Panel C41, Revision 8
7.4.17, Drywell Continuous Atmospheric Monitoring System, Revision 45
8.5.2.10, RHR Piping Temperature and Pressure Monitoring, Revision 16
8.9.1, Emergency Diesel Generator and Associated Emergency Bus Surveillance, Revision 134
8.9.13, Diesel Generator Alternate Shutdown Panel Test, Revision 19
8.C.13-2, Residual Heat Removal and Core Spray Augmented IST Manual Valve Operability,
Revision 0
8.E.10, LPCI System Instruments Calibration, Revisions 49 & 50
8.I.11.3, Residual Heat Removal A Loop Valve Cold Shutdown Operability, Revision 10
8.M.1-11, Turbine Stop Valve Closure Test, Revision 41
8.M.1-32.4, Analog Trip System - Trip Unit Calibration - Cabinet C2229-B2 Critical
Maintenance, Revision 65
8.M.2-1.5.5, Residual Heat Removal (RHR) Isolation Valve Control - Test B Outboard Reactor
Pressure Less Than 70 Psig - Critical Maintenance, Revision 32
Attachment 2
A2-10
8.M.2-2.10.2-11, RHR System Pump P-203C Automatic Start Functional Test, Revision 36
8.M.2-2.10.8.5, Diesel Generator A Initiation by Loss of Offsite Power Logic Critical
Maintenance
8.M.2-3.3, Source Range Monitor, Revision 52
8.M.3-14, H2/O2 Analyzer System Calibration Critical Maintenance, Revision 42
8.M.3-2, Instrument Line Flow Check Valve Functional Test Critical Maintenance, Revision 45
EN-AD-101, Procedure Process, Revision 27
EN-DC-148, Vendor Manuals and the Vendor Re-Contact Process, Revision 6
EN-DC-151, PSA Maintenance and Update, Revision 6
EN-DC-153, Preventive Maintenance Component Classification, Revision 14
EN-DC-324, Preventive Maintenance Program, Revision 17
EN-DC-329, Engineering Programs Control and Oversight, Revision 6
EN-DC-336, Plant Health Committee, Revision 10
EN-DC-346, Cable Reliability Program, Revision 6
EN-EC-100, Guidelines for Implementation of Employee Concerns Program, Revision 9
EN-EC-100-01, Employee Concern Coordinator Training Program, Revision 1
EN-FAP-HR-004, Developing and Implementing Knowledge Management Action Plans
EN-FAP-HR-006, Fleet Approach to Leadership Development & Organizational Effectiveness,
Revision 1
EN-FAP-OM-001, Leadership forums for Continuous Improvement, Revision 26
EN-FAP-OM-002, Management Review Meetings, Revision 6
EN-FAP-OM-011, Corporate Oversight Model, Revision 17
EN-FAP-OM-016, Performance Management Processes and Practices, Revision 6
EN-FAP-OM-021, Critical Decision Procedure, Revision 5
EN-FAP-OM-023, Entergy Nuclear Change Management, Revision 4
EN-FAP-WM-002, Critical Evolutions, Revision 4
EN-FAP-WM-011, Work Planning Standard, Revision 4
EN-FAP-WM-012, Work Management Process Indicators, Revision 6
EN-HR-135, Disciplinary Action, Revision 1
EN-HR-138, Executive Review Board Process for Employees, Revision 5
EN-HR-138-01, Executive Review Board Process for Supplemental Employees, Revision 1
EN-HU-101, Human Performance Program, Revision 18
EN-HU-102, Human Performance Traps and Tools, Revision 14
EN-HU-105, Human Performance Manager Defenses, Revision 9
EN-HU-106, Procedure and Work Instruction Use and Adherence, Revision 3
EN-LI-102, Corrective Action Program, Revision 28
EN-LI-102, Corrective Action Program, Revision 26
EN-LI-104, Assessments and Benchmarking, Revision 11
EN-LI-104, Self-Assessment and Benchmark Process, Revision 13
EN-LI-118, Cause Evaluation Process, Revision 23
EN-LI-118, Cause Evaluation, Revision 22
EN-LI-121, Trending and Performance Review Process
EN-LI-123-08-PNP-RC, Comparative Assessment Review, Revision 0
EN-LI-123-10-PNP-RC, Nuclear Safety Culture Assessment, Revision 0
EN-LI-123-11-PNP-RC, Collective Evaluation and Action Plan Development, Revision 1
EN-LI-128, Mid-Cycle Assessment Process, Revision 10
EN-LI-128, Mid-Cycle Assessment Process, Revision 11
EN-MA-130, Fix It Now (FIN) Team Process, Revision 4
EN-OM-123, Fatigue Management Program, Revision 13
Attachment 2
A2-11
EN-OP-104, Operability Determination Process, Revision 10

EN-OP-115, Conduct of Operations, Revision 17
EN-OP-115-01, Operator Rounds, Revision 1
EN-OP-115-02, Control Room Conduct and Access Control, Revision 4
EN-PL-100, Nuclear Excellence Model, Revision 7
EN-PL-187, Safety Conscious Work Environment (SCWE) Policy, Revision 2
EN-PL-190, Maintaining a Strong Safety Culture, Revision 3
EN-QV-109, Audit Process, Revision 32
EN-QV-136, Nuclear Safety Culture Monitoring, Revision 6
EN-TQ-127, Supervisor Training Program, Revision 18
EN-TQ-202, Simulator Configuration Control, Revision 9
EN-WM-101, On-line Work Management Process, Revision 14
EN-WM-104, On Line Risk Management, Revision 15
EN-WM-105, Planning, Revision 16
EP-AD-270, Equipment Important to Emergency Response, Revision 2
EP-AD-302, Facilities and Equipment Surveillances, Revision 8
EP-AD-413, Emergency Communications Test, Revision 7
EP-AD-418, Monthly Testing of the Prompt Alert and Notification System, Revision 14
EP-AD-419, Annual Maintenance of the Prompt Alert and Notification System, Revision 13
EP-AD-601, Emergency Action Level Technical Bases Document, Revision 7
EP-IP-100, Emergency Classification and Notification, Revision 43
EP-IP-260, Emergency Operations Facility (EOF) Operations, Revision 10
EP-IP-261, Technical Support Center (TSC) Operations, Revision 10
EP-IP-262, Operations Support Center (OSC) Operations, Revision 9
EP-IP-310, Offsite Monitoring Team Activation and Response, Revision 11
EP-IP-330, Core Damage, Revision 6
EP-IP-440, Emergency Exposure Controls, Revision 13
JA-PI-01, Analysis Manual, Revision 3
NOP98A1, Procedure Process, Revision 39
TP 15-004, General Procedure for Eddy Current Testing of Heat Exchanger Tubing, Revision 0
TP 15-031, Operation Procedure for the Barker/Diacom S4000NM Snubber Test Machine,
Revision 0
TP 16-001, Tri-Nuclear Filter/Demineralizer Resin Transfer, Revision 0
TP 16-003, Boron-10 Areal Density Gauge for Evaluating Racks (BADGER) Testing, Revision 0
TP 16-018, Turbine Stop Valve Closure Functional Test with Turbine Stop Valve SV-2 Slow
Closure Test Circuit Not Functioning Properly, Revision 0
Procedure Change Forms (DRN No.)

14-00831 14-00894 15-01020
16-00363 16-00417 16-00668
16-00880
T-11 Work Week Schedules

Work Week 1636 (05-Sep-16~12-Sep-16 A Train) Ops
Work Week 1636 (05-Sep-16~12-Sep-16 A Train) Ops
Work Week 1637 (12-Sep-16~19-Sep-16 B Train) Ops
Work Week 1638 (19-Sep-16~26-Sep-16 B Train) Ops
Work Week 1639 (26-Sep-16~03-Oct-16 A Train) Ops
Work Week 1646 (14-Nov-16~21-Nov-16 B Train) Ops
Work Week 1647 (21-Nov-16~28-Nov-16 B Train) Ops
Attachment 2
A2-12
Vendor Manuals and Procedures

Procedure 100-ET-005, Eddy Current Inspection of Non-Ferromagnetic Heat Exchanger Tubes,
Revision 1
Procedure TR-954, Operation Procedure for the Barker/Diacon S4000 NM Snubber Test
Machine from BASIC-PSA, INC., Revision 4
Special Engineering Procedure 28087-000-01, Procedure for Assembly and Testing of the
Boron 10 Areal Density Meter at Pilgrim Nuclear Power Station, Revision 2
V0251, Lubrication Manual, Revision 131
V0303, Byron Jackson Pumps, Revision 38
V0348, Bingham Pumps, Revision 16
V0834, ALCO, Revision 0
Nuclear Safety Culture Monitoring Panel Meeting Minutes

Third Quarter 2014, dated October 16, 2014
Fourth Quarter 2014, dated February 11, 2015
First Quarter 2015, dated April 15, 2015
Second Quarter 2015, dated July 9, 2015
Third Quarter 2015, dated November 2, 2015
Fourth Quarter 2015, dated January 21, 2016
January 2016, dated February 29, 2016
February 2016, dated March 17 and March 24, 2016
March 2016, dated April 28 and May 3, 2016
April 2016, dated May 25, 2016
May 2016, dated June 23, 2016
June 2016, dated July 28, 2016
July 2016, dated August 26, 2016
August 2016, dated September 22, 2016
September 2016, dated October 24, 2016
Emergent Meeting for CR-PNP-2016-8280, dated October 31, 2016
October 2016, dated November 18, 2016
November 2016, dated December 8, 2016
Miscellaneous Safety Culture Documents

Safety Culture Lead Team (SCLT) Monitor report for Fourth Quarter 2015 and January 2016,
dated March 21, 2016
White Paper for NSC, SCWE and Anonymous CR Response
Nuclear Safety Culture Interim Actions Report #48, dated November 16, 2016
Nuclear Safety Culture Code Dataset, Dataset List for Trend Code NP11 (NRC P.1)
Identification
Nuclear Safety Culture Code Dataset, Dataset List for Trend Code NWP4 (NRC H.8)
Nuclear Safety Culture Code Dataset, Dataset List for Trend Code NLA1 (NRC H.1)
Nuclear Safety Culture Code Dataset, Dataset List for Trend Code NPA1 (NRC X.6)
Nuclear Safety Culture Monitoring Panel Worksheet, November Dept Info Sheet, for December
8, 2016 NSCMP
Pilgrim Nuclear Power Station 95003 Recovery Plan, Integrated Nuclear Safety Culture
Assessment Report (INSCAR)
Station Update Meeting Slides for disseminating 2016 Synergy Survey results, dated July 13,
2016
Attachment 2
A2-13
2016 Independent Nuclear Safety Cultural Assessment Pilgrim Nuclear Power Station slides,
dated June 15, 2016, provided to all first line supervisors and above
2016 PNPS INSCA Final Results Report and Appendices
2016 PNPS INSCA - Site PowerPoint Presentation
2016 PNPS INSCA - Management PowerPoint Presentation
CR-PNP-2016-2052-060, Provide Gap Refresher Nuclear Safety Culture Training
Nuclear Safety Culture Slides Respectful Work Environment, dated June 1, 2016
Nuclear Safety Culture Slides Problem Identification and Resolution, dated August 1, 2016
Nuclear Safety Culture Slides Effective Safety Communication, dated May 23, 2016
Nuclear Safety Culture Slides Leadership Safety Values and Actions, dated August 22, 2016
Nuclear Safety Culture Slides Decision-Making
Pilgrim Nuclear Power Station 95003 Recovery Plan, Integrated Nuclear Safety Culture
Assessment Report (INSCAR),
Station Update Meeting Slides for disseminating 2016 Synergy Survey results, dated July 13,
2016
2016 Independent Nuclear Safety Cultural Assessment Pilgrim Nuclear Power Station slides,
dated June 15, 2016, provided to all first line supervisors and above
CR-PNP-2016-04261, actions in response to INSCAR, CRs 1 through 91
Nuclear Safety Culture Offsite Meeting slides, dated July 12, 2016
NSC Attendance Rosters, dated January 11, 2016
SCLT Monitor report for Feb-April Review, dated June 3, 2016
Nuclear Safety Culture Slides Work Processes, dated June 26, 2016
FSEM-SUPV-NSC, Rev. 1, Nuclear Safety Culture, dated July 2016
Nuclear Safety Culture Slides Continuous Learning, dated June 20, 2016
Nuclear Safety Culture Slides Questioning Attitude, dated July 21, 2016
Work Orders
00325532-01 00325532-02 00325532-03
00438020-02 00460039-01 52429570-01
52581882-01
Training Documents
O-RQ-04-01-238, Operability Determination Functionality Assessment Fundamentals,
Revision 0
Lesson Plan PGAT-ADM-NSCCAP, Improving Our Nuclear Safety Culture, dated November 4,
2016
FCBT-GET-PATSS, Entergy Fleet Plant Access Training
PGAT-ADM-NSCCAP, Rev. 2, Improving Our Nuclear Safety presentation slides and case
studies
Module #O-RO-03-04-13; Scenario #01; EOP-01/03, Loss of Off-Site Power, Small Break
LOCA, Loss of RPV Injection, Steam Cooling and Emergency Depressurization
Required; Revision 3
Audit/Assessment Reports
Assessment Report, Assessment of Pilgrim Station Employee Concerns Program, dated March
2013
Assessment Report, Assessment of Pilgrim Station Employee Concerns Program, dated
November 2014
Focused Self-Assessment: Pre-NRC 95003 Preventive Maintenance Program, dated August 17,
2016
Operational Focus Meeting Planned Schedule/Desired Attendees/Proposed Agendas
Attachment 2
A2-14
Operations - Snapshot - Interim Controls HU, dated December 31, 2015

Performance Improvement - Snapshot - Interim Controls CAP, dated January 30, 2016
PNPS 95003 Inspection Readiness Assessment Report dated September 2, 2016
PNPS Comparative Assessment Review Assessment Area Report
PNPS IACPD Allocation of Resources Performance Area Report
PNPS Identification, Assessment & Correction of Performance Deficiencies (IACPD)
Assessment Area Report
QA-16-005, Monthly Recovery Plan Follow-up (June 2016), dated July 27, 2016
QA-16-008, Monthly Recovery Plan Follow-up (September 2016), dated October 14, 2016
QA-16-010, Monthly Recovery Plan Follow-up (October 2016), dated November 15, 2016
QA-16-011, Monthly Recovery Plan Follow-up (November 2016), dated December 15, 2016
QA-5-2016-PNP-1, Document Control/Records Management, Licensing, Operations,
Maintenance, and Security, dated October 19, 2016
Self-Assessment - Production / Outage - EN-FAP-OU-110 (Critical Maintenance Identification
and Oversight), dated September 29, 2016
Self-Assessment of Entergy Vendor Manuals and Vendor Re-contact Process
(LO-PNPLO-2016-00033), dated June 30, 2016
Self-Assessment: Entergy Nuclear North Pre-NIEP Assessment of Nuclear Independent
Oversight/Quality Assurance, dated June 16, 2016
Snapshot Assessment - Air Operated Valve Program, dated August 31, 2016
Snapshot Assessment - Check Valve Maintenance and Monitoring Program, dated August 31,
2016
Snapshot Assessment - Engineering (Recovery) - Predictive Maintenance Program, dated
September 29, 2016
Snapshot Assessment - Engineering Director (Recovery) - Engineering Health Reports, dated
September 30, 2016
Snapshot Assessment - Fatigue Rule Compliance, dated August 3, 2016
Snapshot Assessment of Interim Procedure Quality Reviews (LO-PNPLO-2015-00162, CA007),
dated August 8, 2016
dated August 29, 2016
dated October 3, 2016
dated November 18, 2016
Drawings
Drawing No. 29050, 345 One Line & Relay Diagram, Revision 12
Drawing No. 29053, 345 Schematic Diagram CTs & PTs STA650-Switchyard, Revision 31
Drawing No. E1, Single Line Diagram Station, Revision 24
Miscellaneous
10CFR50.54(q) Screening: Adoption of the Unified RASCAL Interface for Emergency Dose
Assessment
10CFR50.54(q) Screening: Emergency Action Level Technical Bases Document (EALs HU1.1
and HU4.1
10CFR50.54(q) Screening: Emergency Action Level Technical Bases Document, (EAL Table F-3
Secondary Containment Area Temperature and Radiation Maximum Safe Operating
Values)
2016 Annual Siren Test Results
2016 Assessment Schedule
Attachment 2
A2-15
2016 Pilgrim Mid-Cycle Assessment Final Report

4th Quarter Quarterly ERF Facilities Surveillance
95003 Pilgrim Recovery Action Timeline
Composite AP-913 Equipment Reliability Index and Industry Guidance Document, Revision 6
Condition Analysis for Turbine Stop Valve Failure to Stroke
Condition report list with procedure quality in the condition report description from June 2016
through November 2016
Condition report list with trend code equal to procedure quality from June 2016 through
November 2016
CR-PNP-2016-2052, CA-60; Training Attendance List
Dynamic Learning Activity (DLA); FDLA-ADM-FUNDMNTL_000-1; Revision 0
ECP Investigation Plan Guidelines
ECP Investigation Report Format Guidance
ECP Investigation Scope and Depth Guidelines
Email from David Noyes to Peter Miner, Information Request 006ED (partial) dated
November 23, 2016
Email from Philip Chase to David Noyes, Priority Organization Action Plans, dated
December 6, 2016
EN-FAP-OM-016, Attachment 7.1, Monthly Performance Management Meeting records
(various)
EOF HVAC System Maintenance and Testing, December 2016
ER and RR and DM mentoring Project Plan, dated September 30, 2016
FFAM-ECPI-INIT, Employee Concerns Coordinator Familiarization Guide, Revision 1
FFAM-SUPV-0001, Supervisory Training Program Familiarization Guide, Revision 13
Fleet Refocus Observation WILL Sheet
Guidelines for Administration of the Employee Concerns Program
List of 1.3.142 Risk Reviews completed since 04/25/2016
Maintenance CFAM November 2016 Report
Maintenance CFAM September 2016 Report
Maintenance Fundamentals MA-3 Conservatism & Risk
Most Error Likely Task COACH Briefing Summary Report
NIOS Escalation Letter QA-16-009: Work Management, dated October 18, 2016
NIOS Quality Assurance Audit Report Emergency Preparedness, dated March 28, 2016
NIOS Quality Assurance Audit Report Fire Protection, dated January 11, 2016
NIOS Quality Assurance Audit Report Maintenance, dated June 6, 2016
Nuclear Safety Culture Monitoring Panel Reports (various)
Operating Experience Couplings Using EP 111 Compared with Manufacturer/Supplier
Recommendations
Operating Experience ICES 189941, Failure of Main Generator Stator Cooling System
Mechanical Coupling That Supports Main Generator Stator Cooling System Centrifugal
Pump 7T051MPA002
People Health Committee Meeting Agenda dated December 16, 2016
Performance Improvement CFAM April 2016 Report
Performance Improvement CFAM February 2016 Report
Performance Improvement CFAM July 2016 Report
Pilgrim 95003 Mentor Team Report (various)
Pilgrim 95003 Mentor Team Report, dated November 30, 2016
Pilgrim 95003 Mentor Team Report, dated November 4, 2016
Pilgrim 95003 Mentor Team Report, dated October 21, 2016
Pilgrim Equipment Reliability and Risk Recognition and Decision Making Mentor Team Project
Plan, dated September 12, 2016
Attachment 2
A2-16
Pilgrim Handbook, Building Our Legacy of Excellence

Pilgrim Mentors Resumes and List of Roles/Responsibilities
Pilgrim NIOS Staffing Organizational Chart
Pilgrim Security Standing Order SO#2015-002, Security Communications Methods, Revision 1
Pilgrim Site Work Schedules (various)
Pilgrim Station 95003 HU Observation Form
Pilgrim Station Backlog Detail Priority 2, dated December 8, 2016
Pilgrim Station Backlog Detail Priority 3, dated December 8, 2016
Pilgrim Station Coordinated Meeting Schedule
Plant Health Committee Agenda, dated November 28, 2016
PNPS Comprehensive Recovery Plan, Revision 1
PNPS Emergency Plan Section E, Notification Methods and Procedures, Revision 47
PNPS Emergency Plan Section F, Emergency Communications, Revision 47
PNPS Emergency Plan Section H, Emergency Facilities and Equipment, Revision 47
PNPS Emergency Plan Section I, Accident Assessment, Revision 47
PNPS EOP/SAG Design Considerations, Revision 10
PNPS ERO Team Roster (January 2016)
PNPS Plant-Specific Technical Guidelines & Severe Accident Technical Guidelines, Revision 10
PNPS Procedure Use and Adherence WILL Sheet
PNPS Siren Performance Monthly Report (November 2016)
Power Point Presentation: Pilgrim People Health and Workforce Planning Strategy CA-56 and
CA-57; December 2016
PPA AP-907-05, Procedure Writers Manual, Revision 2
PSA-PNPS-06-001, PNPS 2013 PSA Update Applications Review Maintenance Rule
RC03.2011.10 (Eliminate PASS from TS; Develop and Maintain Contingency Plans)
Response to CFAM Elevation: Preventative Maintenance Process Indicators not Meeting Fleet
Standards (CR-2016-175), dated January 12, 2016
Response to CFAM Elevation: Work Management Indicators not Meeting Fleet Standards (CR-
2016-176), dated January 12, 2016
Response to NIOS Elevation Letter - Maintenance Repetitive Red-Yellow Functional Area Ratio
(CR-PNP-2016-03090), dated May 6, 2016
Response to NIOS Escalation Letter for Work Management - NIOS (CR-PNP-2016-08099),
dated December 17, 2016
Response to NIOS Escalation Letter for Work Management NIOS, dated November 6, 2016
Reviewed PNPS Procedure Quality Technical Review WILL sheets performed during the
T-11 schedule weeks for work weeks 1636 to 1702 for the following groups: operations,
radiation protection, electrical maintenance, instrumentation and controls maintenance,
and mechanical maintenance
Reviewed System Risk Ranking, Revision 0
T-2 Technical Rigor Meeting, Week 1560, B Division, dated December 5, 2016
Targeted Performance Improvement Plans (TPIPs) (various)
White Paper, Intent Change Basis for CR-PNP-2016-2056, CA-35 & CA-36 and CR-PNP-2016-
2052, CA-45 (undated)
White Paper: Corrective Actions with Intent Changes after Completion; undated
White Paper: Intent Changes Bases for CR 16-2056, CA-35 and CA-36; and CR 16-2052,
CA-45
White Paper: Resource Needs Analysis and Results; undated
Attachment 2
A2-17
LIST OF ACRONYMS
ADAMS Agencywide Documents Access and Management System

ANO Arkansas Nuclear One
ASME American Society of Mechanical Engineers
CAPR corrective action to preclude repetition
CFR Code of Federal Regulations
CR condition report
EAL emergency action level
EC engineering change
EFR effectiveness review
EPRI Electric Power Research Institute
IMC Inspection Manual Chapter
IP Inspection Procedure
KV kilovolts
LOOP loss of offsite power
M megaohms
MORT Management Oversight Risk Tree
NIOS Nuclear Independent Oversight
NRC Nuclear Regulatory Commission
PNPS Pilgrim Nuclear Power Station
SBO station blackout
SRV safety/relief valve
UFSAR Updated Final Safety Analysis Report
WILL what it looks like
Attachment 2

Pilgrim 2016011 Final

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pilgrim 2016011 Final

Uploaded by

Copyright:

Available Formats

J.

May 10, 2017

Mr. John Dent

SUBJECT: PILGRIM NUCLEAR POWER STATION SUPPLEMENTAL INSPECTION

Dear Mr. Dent:

Adjustments to corrective actions or compensatory measures to assure that the

Inclusion of corrective actions to address the significant weaknesses identified during

A description of how Entergy is planning to address gaps identified by Phase C of the

A review and analysis of the effectiveness of Entergys implementation of subject matter

Additionally, Entergy needs to implement current Comprehensive Recovery Plan actions in a

Docket No. 50-293

cc w/encl: Distribution via ListServ

SUBJECT: PILGRIM NUCLEAR POWER STATION SUPPLEMENTAL INSPECTION

DISTRIBUTION: (via email)

DOCUMENT NAME: G:\DRP\BRANCH5\+++Pilgrim\+++Pilgrim Column 4 Activities\Phase C Inspection Report\Pilgrim 2016011 final.docx

Non-Sensitive Publicly Available

OFFICE RI/DRS RI/DRS RI/DRS RIII/DRP RI/DRP

U.S. NUCLEAR REGULATORY COMMISSION

Docket No. 50-293

License No. DPR-35

Report No. 05000293/2016011

Licensee: Entergy Nuclear Operations, Inc. (Entergy)

Facility: Pilgrim Nuclear Power Station (PNPS)

Location: 600 Rocky Hill Road

Dates: November 28, 2016 January 13, 2017

Inspectors: D. Jackson, Team Leader, Branch Chief, Region I

Senior Reactor Analyst

Problem Identification and Resolution Group

Leadership, Operations, and Oversight Group

Engineering, Maintenance, and Programs Group

S. Elkhiamy, Project Engineer, Region I (training)

Safety Culture Assessment Group

Approved by: Raymond K. Lorson

EXECUTIVE SUMMARY .............................................................................................................. 5

6. Reactor Safety Strategic Performance Area ............................................................. 76

Overall Assessment and Conclusions

Adjustments to corrective actions or compensatory measures to assure that the

Inclusion of corrective actions to address the significant weaknesses identified during

A description of how Entergy is planning to address gaps identified by Phase C of the

A review and analysis of the effectiveness of Entergys implementation of subject matter

Additionally, Entergy needs to implement current Comprehensive Recovery Plan actions in a

PNPS Site Recovery Process (Section 2)

IP 95001: SRV White Finding (Section 4)

Corrective Action Program Fundamental Problem (Section 5)

Decision-Making/Risk-Recognition Fundamental Problem (Section 6.1)

Nuclear Safety Culture Fundamental Problem (Section 7.1)

NRCs Graded Safety Culture Assessment (Section 7.2)

Performance Deficiency Cause Analysis (Section 8)

Weaknesses in Adequacy and/or Implementation of CAPRs. In general, the NRC team

Implementation of Subject Matter Experts at PNPS. Based on a review of the root

Inspection Report 05000293/2016011; 11/28/2016 01/13/2017; Pilgrim Nuclear Power Station;

Cornerstone: Initiating Events

descriptions must be worded to ensure that the adverse condition or cause/factor is

Cornerstone: Mitigating Systems

through the performance of appropriate preventive maintenance, or through performance

Cornerstone: Barrier Integrity

2. Licensee Site Recovery and Comprehensive Recovery Plan

This phase resulted in development of assessment reports and problem descriptions to be

A comparative assessment review to determine whether weaknesses similar to the

A review of the stations identification, assessment, and resolution of performance

A review of the adequacy of programs and processes associated with human

Fundamental Problems Problem Areas

Action Plan Development

Improvement Area Area Action Plan